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DUKE  HOSPITAL  LIBRARY 
DURHAM,  N.  C. 

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PSRMANBNT  LOAN 
^EQR&IA  MEDTr«A][,  gnnTTCT^Y 


. ' #■  # •'  11/ M . 


Digitized  by  the  Internet  Archive 
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ELEMENTS 


OF 

GtENERAL  AND  PATHOLOGICAL 


ANATOMY. 


ELEMENTS 


oi' 

GENERAL  ANE  PATHOLOGICAL 

ANATOMY, 


I'llKSKNTINU  A 

VIEW  OF  THE  PRESENT  STATE  OF  KNOWLEDGE 
IN  THESE  BRANCHES  OF  SCIENCE. 


15V 


DAVID  ClIAIDIE,  M.D.,  E.E.S.E. 

FELLOW  OF  THE  LOYAL  COLLEOE  OF  niYSICIAXS,  EHl.N  BUlUi  H, 
AND  UOXOKAKY  COXSELTIXG  PHYSICIAN' 

TO  THE  LOYAL  IXFILMALY. 


SECOND  EDITKJN, 

ENLARUKC,  REVISED,  AND  IMDROVED. 


P H I L A D E L P n I A ; 

LINDSAY  AND  BLAKISTON. 

1 <S51. 


PREFACE 


TO  THE  FIRST  EDITION. 


The  value  of  Morbid  Anatomy  as  the  basis  of  rational  Pathology 
was  early  recognized  by  physicians;  and  the  works  of  Wepfer, 
Gerard  Blasius,  Schenke,  Pechlin,  Harder,  Plater,  Van  der  Wiel, 
and  Fantoni,  demonstrate  the  diligence  with  which  the  pathologists 
of  the  17th  century  laboured  to  investigate  the  nature  and  effects 
of  morbid  action.  The  elaborate,  but  somewhat  confused,  collection 
of  Bonetus  was  the  first  attempt  to  classify  the  facts  observed  by 
these  and  previous  authors.  To  Morgagni,  however,  was  reserved 
the  merit  of  publishing  a work,  distinguished  equally  by  critical 
knowledge  of  the  labours  of  his  predecessors  and  contemporaries, 
and  by  accurate  personal  observation.  From  the  days,  indeed,  of 
Fantoni,  Valsalva,  and  Morgagni,  to  those  of  Sandifort,  Baillie, 
Meckel,  and  Laennec,  the  study  of  Morbid  Anatomy  has  been  as- 
siduously cultivated  by  all  who  were  interested  in  the  progress  of 
accurate  knowledge. 

At  no  period,  however,  has  this  department  of  science  been  pur- 
sued with  greater  zeal  than  during  the  last  twenty  years,  in  the 
course  of  which  the  observation  and  collection  of  pathological  facts 
has  engrossed  the  attention  of  numerous  observers,  both  in  this 
country  and  in  France  and  Germany.  Of  this  the  result  has  been, 
more  accurate  distinction  of  diseases  formerly  confounded,  fuller 
and  more  precise  information  regarding  those  which  were  imper- 
fectly known,  and  an  extraordinary  accumulation  of  matter  on  all 
topics.  In  some  instances  the  boundaries  of  tbe  science  have  been 
extended ; in  others,  departments  already  known  have  been  more 


VI 


PREFACE. 


diligently  explored;  and  if  the  result  has  not  at  all  times  been  ab- 
solute discovery,  some  advantage  has  accrued  from  the  correction 
or  the  modification  of  former  statements. 

The  advantage  to  the  science  at  large  has  nevertheless  been  ac- 
companied with  great  and  increasing  inconvenience  to  the  student. 
The  recorded  information  is  scattered  through  so  many  volumes, 
that  the  usual  period  allotted  to  the  acquisition  of  knowledge  is 
quite  inadequate  to  consult  them  in  the  most  cursory  manner. 
Many  of  the  most  valuable  papers  also  are  contained  in  periodical 
works,  in  which  it  is  not  always  easy  to  peruse  them.  In  short,  so 
great  is  the  accumulation  of  materials,  yet  so  dispersed  and  mul- 
tiplied, that  the  most  intrepid  diligence  is  disconcerted,  and  the 
most  indefatigable  perseverance  is  exhausted. 

To  alleviate,  if  not  to  remove,  some  of  these  difficulties,  the  most 
obvious  plan  is  to  classify  the  principal  facts,  which  it  is  important 
for  the  student  to  know  ; to  reduce  to  general  heads  the  numerous, 
isolated,  and  not  unfrequently  unarranged  facts,  recorded  by  diffe- 
rent observers ; to  reconcile  what  is  discordant ; to  explain  what  is 
anomalous ; to  distinguish  the  essential  from  the  accidental, — the 
important  from  the  trivial ; and  to  exhibit  in  a connected  and  sys- 
tematic shape  those  deductions  and  inferences,  which  are  justified 
by  accurate  analytic  comparison  of  the  best  authenticated  facts. 
Though  these  are  the  objects  which  have  been  held  in  view  in  the 
composition  of  the  present  volume,  it  can  only  be  determined  by 
others,  with  what  success  they  have  been  attained. 

In  the  arrangement  of  the  materials  of  which  it  consists,  I found 
it  impossible  to  adopt  the  methods  in  ordinary  use.  Without  pre- 
tending to  determine  the  comparative  merits  of  the  methods  of 
Baillie,  Conradi,  Meckel,  and  Cruveilhier,  each  of  which  has  pecu- 
liar advantages,  I may  be  permitted  to  observe,  that  the  first  ob- 
ject in  tracing  the  progress  and  effects  of  pathological  processes  is 
to  fix  the  boundary  between  what  is  sound  and  what  is  morbid,  and 
that  every  morbid  process  always  bears  some  relation  to  the  proper 
characters  of  the  texture  in  a sound  state.  For  these  reasons,  I 
have  chosen  as  the  basis  of  arrangement,  the  distinctions  of  the  com- 


PREFACE. 


vn 


ponent  tissues  of  the  animal  body,  as  derived  from  the  similitude 
and  difference  of  their  anatomical  characters  ; and,  though  the  ad- 
vantages of  this  method  have  been  recognized  by  John  Hunter, 
Carmichael  Smyth,  Bichat,  Dr  Thomson,  and  Bedard,  I am  not 
aware  that  any  complete  system  of  pathological  anatomy  has  been 
hitherto  constructed  according  to  its  principles.  The  present  at- 
tempt is,  I believe,  the  first  instance,  in  which  it  has  been  carried  to 
the  length  of  a full  though  elementary  treatise. 

It  is  almost  superfluous  to  enter  into  any  detailed  account  of  the 
principles  on  which  this  work  is  composed.  In  describing  both  the 
sound  and  morbid  states  of  the  different  organic  tissues,  I have  in 
general  indicated  the  sources  of  my  information.  On  the  subject 
of  the  normal  or  healthy  states,  without  neglecting  the  labours  of 
previous  authors,  it  has  been  my  study  to  give  accurate  descriptions 
of  the  objects  from  frequent  and  careful  personal  dissection.  What- 
ever I have  stated  on  my  own  authority  has  been  from  repeated  and 
rather  elaborate  examination ; and  if  I have  erred  or  misrepresent- 
ed, it  is  not  from  carelessness  or  indiflference  in  the  endeavour  to 
insure  accuracy. 

In  describing  the  pathological  changes  incident  to  each  tissue,  it 
has  been  my  study  not  so  much  to  speak  from  personal  observation, 
as  to  generalize  with  fidelity  the  results  of  the  researches  of  others. 
In  a subject  so  extensive  and  so  complicated  as  Morbid  Anatomy, 
individual  observation  and  research  are  of  little  avail,  unless  as  they 
tend  to  confirm,  to  correct,  or  to  modify  the  results  obtained  by 
other  inquirers.  The  duty  of  the  author  of  an  elementary  treatise 
in  such  circumstances  is  chiefly  to  compare  and  generalize  these  re- 
sults. For  these  reasons,  I have  seldom  spoken  of  what  I have 
seen  myself,  unless  where  that  tended  either  to  confirm  some  un- 
certain inference ; to  settle  some  controverted  or  ambiguous  point ; 
or  to  verily  views,  in  favour  of  which  information  was  either  scanty, 
deficient,  or  contradictory.  I must,  however,  say,  that,  in  adducing 
the  testimony  of  other  observers,  I have  in  no  instance  spoken  on 
subjects  which  I have  not  taken  care  to  verify  myself.  Of  every 
morbid  change  described,  the  description  is  derived  in  some  instan- 


Vlll 


PEEFACE. 


ces  from  repeated  inspection, — in  all  from  more  or  less  personal 
examination  of  its  physical  and  anatomical  characters.  Of  my  own 
observation,  however,  I say  nothing,  but  leave  the  reader  to  judge 
both  of  its  extent  and  its  accuracy. 

Though  I have  been  thus  studious  to  avoid  intentional  errors,  it 
is  possible  that  many  have  been  committed  in  the  course  of  the  vo- 
lume, both  from  ignorance  and  from  oversight.  These  I will  not 
extenuate  by  any  apology  derived  either  from  the  ditliculty  and  com- 
plicated nature  of  the  subject,  or  from  the  calls  of  other  professional 
engagements.  When  such  apology  is  admissible,  its  first  interpre- 
tation is, — that  the  author  should  have  left  the  undertaking  to  some 
one  better  qualified  by  opportunities  and  attainments  to  execute  it 
creditably.  On  some  points  I have  gone  less  into  detail  than  the 
nature  of  the  subject  may  seem  to  require  ; on  others  unnecessary 
diffuseness  may  be  perceived ; and  in  some,  perhaps,  omissions  may 
be  detected. 

In  the  section  on  the  Diseases  of  the  Nerves,  though  I refer  to 
the  cases  of  Mojon  and  Covercelli,  I confess  that  I had  at  the  time 
some  doubts  regarding  the  connection  between  existence  of  the  tu- 
mour and  the  epileptic  motions.  Since  that  sheet  was  printed  I 
met  with  the  remarkable  case  of  Dr  Short,*  which  has  tended  to 
remove  these  doubts  ; and  I have  elsewhere  offered  a conjecture  on 
the  connection  between  these  tumours  and  the  sensation  called 
epileptic  aura.  This  it  was  unnecessary  to  notice,  had  not  my 
friend,  Mr  William  Wood,  attaching  to  the  conjecture  more  value 
than  it  really  merited,  resumed  with  his  usual  acuteness  the  inves- 
tigation of  a subject,  on  which  he  was  the  first  to  communicate  ex- 
act information.  The  monograph  of  Mr  Wood,  published  in  the 
third  volume  of  the  Edinburgh  Medico-Chirurgical  Transactions, 
is  now  not  only  the  fullest,  but  the  best  account  of  the  neuroraatic 
tubercle  ; and  had  it  been  composed  previous  to  the  sheet  in  which 
the  account  in  the  present  volume  is  contained,  would  have  enabled 
me  to  give  a much  better  description  of  that  disease. 

To  the  peculiar  disease  of  the  intestinal  mucous  membrane  in 

* Medical  Essays  and  Observations,  Vol.  iv.  p.  416. 


PREFACE. 


IX 


children  described  by  Dr  Crampton,  I have  not  assigned  a separate 
place  in  the  text,  from  difficulty  of  understanding  its  exact  nature. 
In  some  of  the  cases  recorded  by  that  physician,  the  villi  seemed 
converted  into  tubercles.  In  others  the  presence  of  pustular  ulcers 
not  unlike  small-pox  seems  to  indicate  the  usual  follicular  disease 
of  that  membrane.  And  in  others  the  granular  appearance  of  the 
villous  membrane  appears  to  correspond  with  the  usual  effects  of 
dysenteric  inflammation.  These  appearances  the  ingenious  author 
of  the  account  ascribes  to  inflammation  operating  on  the  strumous 
habit.* 

The  work  of  Dr  Abercrombie  on  the  Pathology  of  the  Intestinal 
Canal,  I did  not  receive  till  the  sheets  on  the  diseases  of  the  Mu- 
cous and  Serous  Membranes  were  printed.  It  was  therefore  im- 
possible for  me  to  avail  myself  of  the  researches  of  that  acute 
observer. 

On  one  department  of  Pathological  Anatomy  the  reader  will 
find  little  or  no  information  in  the  present  volume.  I allude  to 
local  diseases,  and  to  those  varieties  of  malformation  which  consist 
in  misapplications  of  the  component  parts  of  organs.  These,  it  is 
almost  superfluous  to  remark,  cannot,  without  violation  of  the  prin- 
ciples of  arrangement,  be  introduced  in  a work  on  General  Ana- 
tomy ; and  I have  therefore,  however  reluctantly,  excluded  them 
almost  entirely,  unless  so  far  as  their  general  characters  could  be 
stated. 

Farther,  it  was  my  intention  to  conclude  the  work  with  an  ac- 
count of  the  healthy  structure  and  the  morbid  changes  of  the  glan- 
dular system.  I found  it,  however,  difficult  to  give  such  a general 
sketch  of  the  healthy  anatomy  of  these  oi’gans  as  would  be  appli- 
cable to  all  without  being  untrue  of  any, — and  by  no  means  easy, 
without  swelling  a volume  already  too  large,  to  exhibit  such  a view 
of  the  anormal  deviations  as  would  be  either  just  or  useful.  This, 
therefore,  I am  obliged  to  defer  for  the  present. 

Lastly,  The  limits  within  which  it  is  requisite  to  confine  this 
work,  principally  intended  for  the  student  of  pathology,  have  com- 


Dublin  Reports,  Vol.  ii.  p.  286. 


X 


PREFACE. 


pelletl  me  to  touch  very  cursorily  on  many  points,  which,  from 
their  importance,  would  have  required  fuller  details.  Though  I 
have  throughout  been  solicitous  to  present  the  unbroken  chain  of 
evidence,  on  which  the  inferences  and  deductions  are  made  to  rest, 
I have  often  been  obliged  to  state  the  latter  only,  and  in  a form 
perhaps  too  dogmatic,  with  the  view  of  saving  the  time  of  the 
reader.  In  no  instance,  however,  has  this  been  done  without 
deliberate  examination  of  the  authorities  for  every  fact,  and  of  the 
evidences  for  each  conclusion.  On  ordinary  points,  on  which 
pathological  opinion  is  unanimous,  I have  been  sparing  of  reference, 
or  omitted  it  entirely.  On  subjects,  on  the  contrary,  on  which 
information  is  doubtful  and  scanty,  or  on  which  there  is  room  for 
diversity  of  sentiment,  I have,  by  referring  the  reader  to  the  best 
sources,  enabled  him  to  appreciate  the  validity  of  the  conclusions 
stated.  Without  attempting,  however,  to  refer  to  all  the  authori- 
ties extant,  w'hich  must  have  uselessly  enlarged  the  work,  I have 
directed  him  chiefly  to  those  which  are  at  once  most  useful  and 
most  accessible. 


Edinburgh,  ith  November  1828. 


ADVERTISEMENT. 


In  preparing  the  present  Edition  all  the  materials  of  the  first 
have  been  employed.  But  they  have  been  greatly  increased  by 
the  introduction  of  new  matter  under  the  proper  heads,  in  order 
to  carry  forward  to  the  present  time  the  information  acquired 
since  the  appearance  of  the  first  edition.  Numerous  rectifications, 
both  in  healthy  and  morbid  anatomy,  have  also  been  made. 

Besides  the  changes  now  mentioned,  two  new  books  have  been 
added ; one  on  the  Structure  and  Morbid  States  of  the  Glands ; the 
other  on  the  Structure  and  Morbid  States  of  the  Lungs  and  Heart. 

The  object  of  the  author  throughout  the  volume  has  been  to 
communicate  precise  and  useful  information  in  a perspicuous  and 
methodical  manner.  Of  the  difficulties  attending  the  undertaking 
he  is  fully  aware ; and  it  is  possible,  that,  after  all  endeavours  to 
render  the  work  perfect,  it  may  still  present  defects.  In  a subject 
so  extensive  and  complicated  as  morbid  anatomy,  and  which  is  cul- 
tivated by  so  many  assiduous  inquirers,  the  difficulty  of  presenting 
the  most  recent  views  must  always  be  great.  This,  however,  the 
author  has  studied  to  do,  so  far  as  the  limits  of  the  work  permit. 

Novelty,  however,  is  not  the  only  object  which  the  author  of  a 
work  on  pathological  anatomy  should  keep  in  view.  His  great 
object  must  be  to  furnish  correct  statements  and  useful  information 
on  the  nature  and  distinctive  characters  of  diseases.  On  this  ac- 
count the  author  has  adhered,  as  formerly,  to  the  principle  of  judi- 
cious selection. 


XU 


ADVERTISEMENT. 


By  some  it  may  be  expected  that  this  work  should  have  been 
illustrated  with  delineations,  more  especially  in  reference  to  mi- 
croscopical anatomy.  These,  however,  would  have  added  so  much 
to  the  expense  of  the  work,  without  otherwise  increasing  its  value, 
that  it  was  thought  best  for  the  present  to  dispense  with  their 
assistance.  The  most  effectual  way  to  obtain  information  in  mi- 
croscopical anatomy  is  for  the  student  to  take  frequent  opportuni- 
ties of  examining,  by  the  microscope,  the  textures  in  their  healthy 
and  diseased  states.  In  this,  as  in  all  other  branches  of  knowledge, 
nothing  can  be  compared  to  practice  and  experience  ; and  no  in- 
formation is  equal  to  that  which  is  obtained  by  frequent  personal 
observation. 

In  conclusion,  the  author  trusts,  that  while  the  work  in  its  pre- 
sent form  may  be  useful  to  students  and  practitioners,  it  is  still 
more  worthy  of  that  degree  of  favour,  with  which  it  was  received 
by  those  distinguished  members  of  the  profession,  whose  approba- 
tion it  must  always  be  an  honour  to  obtain. 

20,  Queen  Street, 
ith  Novemler  1847. 


CONTENTS 


BOOK  I. 

SIMPLE  ELEMENTARY  TISSUES. 


CHAPTER  I. 

Division  of  the  Textures,  . . . Page  1 

CHAPTER  II. 

The  Fluids,  .....  18 

Morbid  States  of  the  Fluids,  , . . 24 

CHAPTER  HI. 

Filamentous  or  Cellular  Tissue,  . . . .30 

The  Diseases  of  Cellular  Tissue,  ...  35 

CHAPTER  IV. 

Adipose  Tissue,  . . . . .49 

Diseases  of  Adipose  Tissue,  ....  55 

CHAPTER  V. 

Ai-teiy, — Ai-terial  Tissue,  . . . .76 

Diseases  of  Ai-teries,  . . . . 87 

CHAPTER  VI. 

Vein, — Venous  Tissue,  . . .112 

Diseases  of  Veins,  ....  124 

CHAPTER  VII. 

System  of  CapUIary  Vessels, — Terminations  of  Ai’teries, — Origins  of 
Veins,  ......  131 

Diseased  States  of  Capillary  Vessels,  . . . 136 

CHAPTER  VIII. 

Erectile  Tissue,  .....  1G9 

Diseases  of  Erectile  System,  ....  176 

CHAPTER  IX. 

System  of  Exhalants,  . . . .187 

Diseases  of  Exhalants,  ....  190 


XIV 


CONTENTS. 


CHAPTER  X. 


Lymphatic  System, 

Diseases  of  the  Lpnpliatic  System, 


Page  204 
210 


CHAPTER  XI. 


Lymphatic  Glaiul  or  Ganglion, 
Diseases  of  Lymphatic  Glands, 


215 

217 


CHAPTER  XII. 

Organization  and  Structure  distinguished. 


253 


BOOK  II. 

NERVOUS  SYSTEM. 

CHAPTER  I. 

Section  I. — Tlie  Central  Portion  of  Nervous  System, — The  Brain,  228 
Section  II. — Morbid  States  of  the  Brain,  . . 277 

CHAPTER  II. 

Section  I. — Nerve, — Nervous  Tissue,  . . 359 

Section  II. — Diseased  States  of  Nerves,  . . 379 


BOOK  III. 

KINETIC  TEXTURES.— STEREOMORPHIC 
TEXTURES. 

CHAPTER  I. 

Flesh,  Muscle, — Muscular  Tissue,  . . . 395 

Diseased  States  of  Muscular  System,  . . . 401 


CHAPTER  II. 


Sinew,  Tendon, 

Diseased  States  of  Tendon, 


412 

413 


CHAPTER  HI. 


White  Fibrous  System, 

Diseased  States  of  White  Fibrous  System, 


414 

417 


CHAPTER  IV. 

Yellow  Fibrous  System  and  Morbid  States, 

4 


420 


CONTENTS.  XV 

CHAPTER  V. 

Bone,  .....  Page  427 

Diseased  States  of  Bone,  ....  444 

CHAPTER  VI. 

Gristle,  Cai’tilage,  .....  490 

Diseased  States  of  Cartilage,  . . . 492 

CHAPTER  VII. 

Fibro-CartUage,  .....  494 

Diseased  States  of  Fibi’o-Cartilage,  . . 495 


BOOK  lY. 

MEMBRANOUS  OR  INVESTING  TEXTURES. 

CHAPTER  I. 

Section  I. — Skin,  .....  497 

Section  II. — Diseased  States  of  Skin,  . . . 504 

CHAPTER  II. 

Section  I. — IMiicous  Membrane, — Villons  Membrane,  . 548 

Section  II. — Diseased  States  of  Mucous  Membrane,  . 566 

CHAPTER  HI. 

Section  I. — Serous  Membrane, — Transparent  Membrane,  . 683 

Section  II. — Diseased  States  of  Serous  Membrane,  . 697 

CHAPTER  IV. 

Section  I. — Sjmovial  Membrane,  ....  746 

Section  II. — Diseased  States  of  Synovial  Membrane,  . 748 


BOOK  V. 

THE  GLANDS. 

CHAPTER  I. 

Section  I. — Glands  in  general,  . . 757 

Section  II. — Structiu-e  of  Individual  Glands,  . , 775 

§ I.  The  Salivary  Glands,  . . . 775 

§ IT.  The  Pancreas,  . . . , 775 


XVI 


CONTENTS. 


§ III.  The  Liver,  ....  Page  777 

§ IV.  The  Kidneys,  ....  731 

§ V.  The  Testes,  ....  805 

§ VI.  The  Mamma,  ....  810 

CHAPTER  II. 

Morbid  States  of  the  Glandular  Organs,  . . 811 

Section  II. — Morbid  States  of  Lacrymal  and  Salivary  Glands,  . 813 

Section  III. — Morbid  States  of  Pancreas,  . . 831 

Section  IV. — Morbid  States  of  Liver,  . . . 853 

Morbid  States  of  Gall-Bladder  and  Ducts,  . . 919 

Section  V. — Morbid  States  of  the  Kidney,  . . . 929 

Section  VI. — Morbid  States  of  the  Female  Mamma,  . 963 

Section  VII. — Morbid  States  of  the  Testis,  . . 967 

Section  VIII. — Morbid  States  of  Prostate  Gland,  . 971 


BOOK  VI. 

THE  I;UNGS  AND  HEART. 


CHAPTER  I. 

The  Lungs,  . ....  973 

Section  I.— -Minute  Stractm-e  of  the  Sound  Lung,  . 973 

Section  II.— Morbid  States  of  the  Lungs,  . . .981 

CHAPTER  II. 

Section  I.— The  Heart,— The  Endocardium,  . . 1042 

Section  II. — Morbid  States  of  the  Heart,  . . . 1043 


Index, 


1067 


ELEMENTS 


OF 

GENERAL  AND  PATHOLOGICAL  ANATOMY. 


BOOK  I. 

CHAPTER  1. 

DIVISION  OF  THE  TEXTURES. 

The  Human  Body  has  been  said  to  consist  of  solid  and  fluid 
parts,  the  former  of  which  are  organized,  and  determine  the  shape 
of  the  body  and  its  parts.  In  the  same  manner  the  solid  parts 
were  distinguished  into  simple  and  vital ; the  first  of  which  were 
believed  to  possess  only  the  general  properties  of  matter,  as  weight, 
cohesion,  elasticity,  flexibility,  &c.  but  to  be  destitute  of  sensibility 
and  mobility,  the  great  characteristics  of  the  vital  solids.  Under 
the  head  of  vital  solids  it  is  evident  that  the  brain,  cerebellum^  spi- 
nal chord,  and  nervous  branches  on  the  one  hand,  and  the  whole 
of  the  muscles  on  the  other,  were  comprehended.  Of  the  simple 
solids,  on  the  contrary,  bone,  tooth,  cartilage,  tendon,  and  liga- 
ment were  conceived  to  be  examples.  This  division,  which  was 
made  at  a time  when  the  attention  of  physicians  was  more  attracted 
by  physical  and  mathematical,  than  by  physiological  and  vital  pro- 
perties, may  now  be  safely  set  aside,  while  we  adopt  another  which, 
though  less  scholastic,  is  more  suited  to  the  nature  of  living  bodies. 

In  the  living  body,  it  may  be  observed,  there  is  no  solid  which 
is  not  alive,  and  which  does  not  possess  vital  properties ; and  there 
is  no  vital  solid  which  does  not  possess  all  the  properties  ascribed 
to  the  simple  solid,  or  the  usual  attributes  of  inanimate  matter. 
The  great  characteristic  of  living  or  organic  bodies  is,  that  every 
substance  which  enters  into  their  composition  possesses  not  only 
the  usual  properties  of  matter,  as  weight,  cohesion,  flexibility,  elas- 
ticity, &c.,  but  also  peculiar  properties  not  found  in  inorganic  bo- 

A 


2 


GENERAL  PATHOLOGICAL  ANATOMY. 


dies,  and  which  have  therefore  been  termed  indiscriminately  animal 
or  living  properties. 

Every  animal  body  consists  of  several  kinds  of  organic  sub- 
stance, which  differ  from  each  other  in  various  modes,  and  each 
of  which  is  characterized  by  peculiar  properties.  In  the  human 
body,  and  in  those  of  all  raammiferous  animals,  these  various  kinds 
of  organic  substances  are  believed  to  be  presented  in  their  most 
perfect  state ; and  it  is  to  these  more  especially  that  the  attention 
of  the  pathologist  is  directed,  and  from  their  examination  that  his 
knowledge  is  derived. 

At  an  early  period  of  the  study  of  anatomy,  the  human  body 
was  distinguished  into  various  kinds  of  animal  substance  ; and  we 
find  even  in  the  writings  of  Jacopo  Berenger  of  Carpi,  (1521), 
but  more  distinctly  in  the  great  work  of  Vesalius,  an  enumera- 
tion and  general  description  of  the  different  kinds  of  substance 
found  to  constitute  the  human  body.  The  example  given  by  these 
founders  of  the  science  was  imitated  to  a greater  or  less  extent, 
and  in  different  degrees  of  perfection  by  succeeding  systematists  ; 
and  we  find  in  the  works  of  Riolan,* * * §  Adrian  Spigel,|  Caspar 
and  Thomas  Bartholin, J Dionis,§  Marchettis,||  Willis,*!!  and 
Winslow,**  but  especially  in  the  bulky  compilation  of  Samuel 
CoLLiNS,tt  various  attempts  to  communicate  a just  idea  of  the  in- 

* Joannis  Riolani  Ambiaiii  Medici  Parisiensis  Opera  Omnia.  Parisiis,  1610.  Folio. 

+ Adriani  Spigelii  de  Corporis  Humani  Fabrica,  libri  x.  4to,  1632. 

J Thomse  Bartholini,  Anatomia  Reformata,  ex  [Casparis  Bartholin!  Parentis  Insti- 
tutionibus  omniumque  Recentionom  et  propriis  observationibus.  8vo,  Hagse  Comi- 
tum,  1660. 

§ The  Anatomy  of  Human  Bodies  improved,  &c.,  publicly  demonstrated  in  the 
Royal  Garden  at  Paris,  by  Monsieur  Dionis,  Chief  Surgeon  to  the  late  Dauphiness, 
and  to  the  present  Duchess  of  Burgundy.  Translated  from  the  third  edition.  Lon- 
don, 1703. 

II  Dominici  de  Alarchettis  Anatomia.  Batav.  1652,  4to. 

^ Thoma;  Willis,  M.  D.  Opera  Omnia.  Amstelsedami,  1682.  4to.  Pharmaceutice 
Rationalis.  This  treatise  contains  much  information  on  the  anatomical  structure  of 
the  textures  and  organs. 

**  Exposition  Anatomique  de  la  Structm’e  du  Corps  Humain.  Par  Jacques-Benigne 
Winslow,  de  I’Academie  Royale,  &c.  &c.  A Paris,  1732.  4to. 

A System  of  Anatomy  treating  of  the  Body  of  Man,  Beasts,  Birds,  Fish,  Insects, 
and  Plants,  illustrated  with  many  Schemes,  consisting  of  a variety  of  elegant  Figures 
drawn  from  the  Life,  and  engraven  in  twenty-four  folio  Copperplates.  By  Samuel 
Collins,  Doctor  of  Physic,  Physician-in-Ordinary  to  his  late  Majesty  of  blessed  memory, 
and  Fellow  of  the  King’s  most  famous  College  of  Physicians  in  London,  and  formerly 
a Fellow  of  the  Royal  Foundation  of  Trinity  College,  in  the  most  flourishing  Univer- 
sity of  Cambridge.  In  the  Savoy,  printed  by  Thomas  Newcomb,  1685.  Two  vo- 
lumes folio. 


DIVISION  OF  THE  TEXTURES. 


3 


timate  structure  and  properties  of  the  several  animal  textures.  In 
general,  however,  these  notices  are  meagre  and  scanty.  Sometimes 
they  are  too  generalizing,  and  hastily  refer  every  variety  of  texture 
to  one  or  two  hypothetical  elements ; too  often  they  consist  of  fan- 
ciful conjectures  substituted  for  accurate  observation  ; and  they  are 
never  so  clear  and  satisfactory  as  to  alford  useful  instruction  to  the 
pathological  inquirer. 

Marcello  Malpighi,  born  in  1628,  professor  of  medicine  succes- 
sively in  the  universities  of  Bologna,  of  Pisa,  and  of  Messina,  and 
finally  invited  to  Rome  as  physician  to  Innocent  XII.,  was  the  first 
anatomist  in  whose  hands  the  knowledge  of  intimate  structure  be- 
came a science  of  accurate  observation.  In  this  manner  (1660)  he 
investigated  assiduously  the  minute  structure  of  the  lungs  and  the 
disposition  of  their  vessels ; he  examined  the  omentum,  (1661),  and 
inquired  into  the  manner  in  which  fat  and  marrow  are  secreted ; 
he  studiously  endeavoured  (1665)  to  unfold  by  dissection  and  mi- 
croscopical observation  the  minute  structure  of  the  brain ; he  de- 
monstrated the  organization  of  the  skin,  and  considered  its  con- 
stituents as  the  organ  of  touch ; he  studied  the  structure  of  bone, 
and  exposed  the  errors  of  Gagliardi ; he  traced  the  formation  and 
explained  the  structure  of  the  teeth ; and  he  finally  carried  his 
researches  into  the  substance  of  the  liver,  the  spleen,  the  kidneys, 
and  the  conglobate  glands,  (1666.)  In  these  delicate  and  difficult 
inquiries,  the  observations  of  Malpighi  are  in  general  faithful  to 
nature,  and  his  descriptions  accurate.  The  information  which  he 
collected  was  new  and  curious,  and  it  is  communicated  in  perspi- 
cuous language,  and  in  an  interesting  manner.  He  may  he  justly 
regarded  as  the  founder  of  that  part  of  anatomical  science  which 
treats  of  structure  and  organization  ; and  even  in  the  present  day 
his  writings  on  this  subject  are  by  no  means  destitute  either  of  in- 
terest or  instruction. 

About  the  same  time  (1641)  the  researches  of  De  Graaf  and 
Ruysch  tended  to  throw  some  light  on  the  intimate  structure  of 
several  organs.  De  Graaf,  who  was  young,  while  Malpighi  was 
declining  in  years,  (1664),  studied  particularly  the  structure  of  the 
pancreas,  and  of  the  organs  of  generation  in  both  sexes,  (1668), 
and  at  once  removed  many  popular  errors,  and  communicated  a 
large  proportion  of  accurate  information.  Had  he  not  been  cut 
off  at  the  early  age  of  thirty-two,  (1673),  it  cannot  be  doubted  that 


4 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


his  zeal  in  prosecuting  the  true  knowledge  of  minute  structure 
would  have  greatly  advanced  this  department  of  anatomy, 

Frederic  Ruysch,  (1638),  professor  of  anatomy  and  surgery 
at  Amsterdam,  was  more  fortunate.  Assiduously  devoted  during 
a long  life  to  the  cultivation  of  anatomy,  and  eminent  for  the  per- 
fection to  which  he  carried  the  art  of  injecting,  he  was  enabled  to 
obtain  more  correct  views  than  his  predecessors  of  the  arrangement 
of  minute  vessels  in  the  interior  of  organs,  and  to  demonstrate 
peculiarities  of  organization,  which  had  escaped  the  scrutiny  of 
previous  anatomists.  Scarcely  a part  or  texture  of  the  human 
body  eluded  the  penetration  of  his  syringe ; and  his  discoveries 
were  proportionally  great,  (1665),  His  researches  on  the  lungs, 
on  the  vascular  structure  of  the  skin,  of  the  bones  and  their  epi- 
physes, of  the  spleen,  of  the  glans  penis,  the  clitoris,  (1691),  and  the 
womb,  impregnated  and  unirapregnated,  were  sufficient  to  give  him 
the  reputation  of  a most  able  and  accurate  anatomist,  (1701). 
These,  however,  were  but  a limited  part  of  his  anatomical  labours. 
He  studied  the  minute  structure  of  the  brain,  (1715);  he  demon- 
strated the  organization  of  the  choroid  plexus ; he  described  the 
state  of  the  hair  when  affected  with  Polish  plait ; he  proved  the 
vascular  structure  of  the  teeth;  he  injected  the  dura  mater,  the 
pleura,  the  pericardium,  and  peritoneum;  he  investigated  the 
structure  of  the  synovial  apparatus  placed  in  the  interior  of  the 
joints,  and  he  discovered  many  curious  particulars  relating  to  the 
lacteals,  the  lymphatics,  and  the  lymphatic  glands.  So  assiduously, 
indeed,  did  Ruysch  study  by  injection  the  tissues  and  organs  of 
the  animal  body,  that  it  is  less  easy  to  say  what  he  did  than  what 
he  neglected.  We  are  indebted  to  him  for  many  of  the  facts  of 
which  anatomy  at  the  present  day  consists,  (1731.) 

The  labours  of  these  ingenious  and  indefatigable  inquirers  added 
considerably  to  the  stock  of  accurate  knowledge,  and  tended  to  dif- 
fuse a taste  for  correct  observation  in  the  study  of  the  minute  struc- 
ture of  the  parts  of  the  animal  body.  Not  much,  however,  had 
been  done  for  the  arrangement  of  the  materials  thus  collected. 
Though  many  isolated  facts  had  been  established,  and  several  cu- 
rious discoveries  had  been  made,  they  were  not  yet  digested  in  that 
systematic  order  which  renders  them  useful  to  the  purposes  of  pa- 
thology. 

It  is  in  the  great  work  of  Haller  (1757),  that  we  recognise  the 
first  traces  of  a better  spirit  and  more  philosophical  views.  This 

3 


DIVISION  OF  THE  TEXTURES. 


5 


accomplished  scholar  and  indefatigable  observer  was  the  first  who 
attempted  to  present,  in  a collected  form,  the  most  correct  informa- 
tion on  the  intimate  structure  of  the  animal  tissues.  Assiduous  in 
his  cultivation  of  anatomy,  and  deeply  impressed  with  the  necessity 
of  accuracy  in  research,  Haller  scrutinized  with  the  eye  of  rigorous 
observation  every  point  in  anatomical  structure  advanced  by  his 
predecessors  and  contemporaries.  In  his  description  of  the  cellular 
web,  of  the  adipose  membrane,  of  arterial  texture  of  the  veins,  of 
the  structure  of  the  heart,  of  that  of  the  brain  and  nerves,  of  the 
lungs,  of  the  minute  structure  of  the  muscles,  of  the  membranes, 
and  of  the  organs  in  general,  the  reader  perceives,  that,  while  Hal- 
ler did  not  disdain  to  avail  himself  of  the  results  of  previous  and 
coeval  inquiry,  he  scrupulously  avoided  adopting  what  he  had  not 
verified  by  personal  observation.  The  work  which  he  modestly 
styled  Elements  of  Physiology  shows,  that,  in  extent  of  information 
and  soundness  of  judgment,  he  had  no  rival  in  the  day  in  which  he 
lived ; and  though  something  has  been  added  to  science  since  his 
death,  it  is  more  by  the  combined  efforts  of  many  than  by  the  la- 
bours of  any  individual. 

Amidst  so  much  excellence  it  was  unfortunate  that  the  vain 
search  after  an  elementary  fibre  or  rudiment,  into  which  every  va- 
riety of  animal  substance  was  supposed  to  be  resolved,  led  him  to 
indulge  in  some  fanciful  conjecture  and  gratuitous  generalization.* 

The  distinction  of  the  animal  body  into  separate  kinds  of  texture 
(1757),  thus  introduced  and  recognised,  was  confined  principally  to 
anatomy  and  physiology.  The  merit  of  applying  them  to  pathology 
is  divided  between  William  Hunter,  William  Cullen,  and  John 
Hunter.  The  first,  in  a paper  on  Emphysema,  in  the  second  vo- 
lume of  the  Medical  Observations  and  Inquiries  (1762,)  gave  in 
1757  an  ingenious  account  of  the  difference  between  the  cellular  tex- 

* It  will  scarcely  be  credited  that  Haller  could  speak  of  this  hypothetical  fibre  in 
the  following  terms.  quo  communi  nomine  multiplex  genus  elementorum 

comprehendimus,  et  cujus  discrimina  continuo  exponemus,  communis  toti  humano 
corpori  materies  est,  etiam,  ut  alibi  ostendemus,  cerebro  et  medullae  spinaU.  Fragilis 
aut  molhs,  elastica,  aut  penitus  pirltacea,  longa  absque  fere  latitudine,  vel  lata  ut 
longitudini  par  fere  latitude  sit,  ossa,  cartilagines,  membranas,  vasa,  ligamenta,  tendines, 
musculos,  nerves,  cellulosum  textum,  viscerum  parenchymata,  piles  et  ungues  sola 
constituit.”  Here  it  is  represented  as  constituting  the  most  opposite  animal  substances, 
and  entering  into  the  composition  of  every  texture.  The  composition  of  this  ideal  fibre 
is  not  less  wonderful.  “ Invisibilis  ea  fibra,  quam  sola  mentis  acie  attingimus,  ex  soils 
elementis  terreis  et  glutine,  non  ex  minoribus  fibris  composita,  cum  sui  similibus  abit 
in  duo  conspicua  elementa  solida  corporis  animalis.” 


fi 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


ture  and  the  adipose  membrane,  with  some  observations  on  the  serous 
membranes,  and  showed  in  what  manner  the  respective  properties 
of  each  tend  to  modify  their  different  morbid  states.  In  the  Noso- 
logy, Physiology,  and  First  Lines  of  Dr  Cullen,  (1765,  1769),  we 
find  the  author  making  frequent  allusion  to  the  organic  properties  of 
the  various  substances  which  enter  into  the  composition  of  the  animal 
body,  (1777),  and  employing  these  distinctions  as  the  foundation  of 
his  Pathology.  In  the  hands  of  John  Hunter  this  system  was  carried 
to  still  greater  perfection ; and  his  work  on  Inflammation  contains 
the  rudiment  of  many  of  the  improvements  which  Pathology  has 
derived  from  this  source. 

General  anatomy  was  thus  beginning  to  attain  insensibly  the 
form  of  a science,  and  to  be  cultivated  with  assiduity  as  the  surest 
basis  of  pathological  knowledge.  I must  not  omit  to  mention,  that 
in  the  time  of  the  elder  Hunter  and  Cullen  it  underwent  a valu- 
able improvement  in  the  hands  of  an  ingenious  foreigner.  This 
consisted  in  the  systematic  and  connected  view  which  Andrew 
Bonn  of  Amsterdam  delineated  of  the  mutual  connections  of  the 
membranes  of  the  human  body.  In  his  Inaugural  Dissertation, 
De  Continuationibus  Memhranarum,  published  at  Leyden  in  1763, 
this  author,  after  some  preliminary  observations  on  membranes  in 
general,  and  on  their  structure  and  organization,  unfolds  the  struc- 
ture of  the  skin  and  its  component  parts,  as  ascertained  by  the  best 
anatomists.  He  then  proceeds  to  trace  its  continuation  or  transi- 
tion into  the  mucous  membranes,  which  he  regards  as  productions 
of  the  skin  ; 1.9^,  By  the  eyelids  into  the  lacrymal  passages ; 2d, 
Into  the  external  ear-hole  ; 3<7,  Into  the  nasal  passages  in  the  form 
of  the  Schneiderian,  or  pituitary  membrane ; Adh,  Into  the  mouth, 
throat,  and  Eustachian  tube  and  tympanal  cavity ; 6th^  By  the 
larynx  and  windpipe  into  the  bronchial  tubes  and  lungs ; 6/A,  By 
the  pharynx  and  oesophagus  into  the  stomach  and  bowels,  where, 
at  the  lower  extremity  of  the  rectum,  its  continuity  with  the  skin 
may  again  be  traced.  He  concludes  this  part  of  his  essay  with  a 
sliort  view  of  the  transition  of  the  skin  into  the  mucous  membrane 
of  the  urinary  and  genital  organs,  or  what  has  since  been  named 
the  genito-urinary  surface.  This  may  be  regarded  as  the  first  di- 
vision of  his  subject. 

In  the  second,  in  which  he  treats  of  the  membranes  beneath  the 
skin,  he  considers,  1st,  Those  of  the  muscles,  as  the  cellular  mem- 
brane and  aponeurotic  expansions ; 2d,  The  periosteum  and  peri- 

4 


DIVISION  OF  THE  TEXTURES. 


7 


chondrium,  with  tlieir  modifications  and  uses ; and  shows  that  one 
or  other  of  these  membranes  invests  and  connects  every  bone  of  the 
skeleton. 

In  the  third  division  he  places  the  internal  membranes  of  cavities, 
or  those  which  are  now  denominated  serous  and  fibro-serous  mem- 
branes. He  first  traces  at  great  length  the  course  and  divisions  of 
the  dura  mater  and  -pia  mater,  and  contends  that  they  accompany 
each  nerve  and  nervous  branch ; then  examines  the  coui'se  of  the 
pleura  and  pericardium,  and  the  relations  of  the  mediastinum ; and? 
lastly,  he  describes  the  extent  of  the  peritoneum  and  its  several  di- 
visions in  connection  with  the  organs  contained  in  the  abdominal 
cavity.* 

The  quantity  of  accurate  information  which  Bonn  has  here  col- 
lected, and  the  new  and  interesting  views  which  he  communicates 
are  truly  wonderful.  This  essay  is  one  of  the  best  specimens  of 
correct  and  useful  generalization  which  can  be  imagined ; and  it  is 
an  example  of  the  capricious  nature  of  scientific  reputation,  that, 
while  the  work  of  Bichat,  which  was  published  forty  years  after, 
though  little  more  than  the  thesis  of  Bonn  expanded,  has  given  its 
author  an  imperishable  name,  the  small  treatise  of  Bonn  is  equally 
unknown  and  unregarded,  and  has  scarcely  served  to  rescue  his 
name  from  utter  oblivion. 

I have  already  alluded  to  the  application  of  the  distinctions  of 
general  anatomj^  to  pathology  in  the  writings  of  Cullen  and  John 
Hunter  (1790).  A more  complete  specimen  of  this  was  given  in 
1790  by  Dr  Carmichael  Smith.  In  a paper  published  in  the  se- 
cond volume  of  the  Medical  Communications  of  London,  f this 
physician  took  a view  of  the  phenomena  and  peculiarities  of  inflam- 
mation as  they  are  observed  in  the  different  sorts  of  organic  sub- 
stance found  in  the  animal  body.  This  may  be  regarded  as  the 
first  systematic  attempt  in  this  country  to  trace  the  influence  w'hich 
different  peculiarities  of  structure  exercise  on  the  phenomena  and 
progress  of  morbid  action. 

After  this  time  various  attempts  were  made  to  enumerate  and 

* Specimen  Anatomico-Medicum  Inaugurate  de  Continuationibus  Membranarum, 
quod  publicae  ac  solemni  disquisitioni  submisit,  Andreas  Bonn,  Amsteladamo  Batavus 
ad  diem  14  Octobris  1763.  Extat  in  Thesauro  Dissertationum,  Programmatum,  alio- 
rumque  Opusculorum  Selectorum,  Eduardi  Sandifort,  M.  D.,  &c.  Vol.  II.  Rotterodami, 
1769,  xii.  p.  265. 

f Transactions  of  a Society  for  Promoting  Medical  Knowledge,  Vol.  II.  London, 
1790. 


8 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


classify  the  several  animal  substances  of  which  the  human  body 
consists,  and  to  describe,  in  general  terms,  their  obvious  and  dis- 
tinctive characters  and  properties.  M.  Pinel,  in  his  NosograpMe 
Philosophique,  first  published  in  1798,  made  the  distinctions  of  the 
membranes  and  other  animal  tissues  the  foundation  of  his  arrange- 
ment and  pathology. 

Soon  after  Xavier  Bichat,  (1800),  in  his  Treatise  on  the  Mem- 
branes, gave  a neat  and  comprehensive  view  of  the  general  structure 
of  these  tissues,  and  of  their  connection  with  the  vital  and  morbid 
processes  carried  on  at  their  respective  surfaces.  This,  however, 
was  merely  the  introduction  to  a work  still  more  extensive  and  ela- 
borate. In  his  Treatise  on  the  Membranes  he  confined  himself  to 
the  examination  of  the  structure  and  properties  of  the  mucous,  se- 
rous, and  fibrous  membranes,  and  a short  view  of  the  fibro-mucous 
and  fibro-serous  tissues.  In  his  General  Anatomy,  which  appear- 
ed in  1801,  he  delineated  the  first,  and  perhaps  the  most  perfect 
arrangement  of  the  different  organic  textures  of  the  human  body 
that  has  yet  appeared. 

This  author  considers  the  human  body  as  an  assemblage  of  many 
different  organs  (1801),  each  of  which  consists  of  a greater  or  smaller 
number  of  animal  substances,  which,  though  thus  combined  in  the 
formation,  or  entering  into  the  composition  of  the  same  part  or  or- 
gan, are  very  different  in  structure  and  properties  from  each  other. 
Each  of  these  distinct  forms  of  animal  matter  he  calls  a tissue  or 


texture,  {textus,  tela ;)  and  he  refers  the  whole  of  those  which  ana- 
tomists have  enumerated,  or  which  accurate  discrimination  can  dis- 
tinguish in  the  human  body,  to  twenty-one  general  heads. 


( Subcutaneous,  connecting  the  skin  to  the  subjacent  parts. 

Subserous,  connecting  the  serous  or  transparent  membranes  to  the  contiguous 
parts. 

Sulrmucous,  connecting  the  mucous  membranes  to  the  subjacent  parts. 
Arterial,  surrounding  and  enclosing  arteries. 

Venous,  ...  ...  veins. 

Excretory,  ...  ...  excretory  ducts. 

Enveloping,  surrounding  and  enclosing  organs. 

L Penetrating,  entering  into  the  substance  of  organs. 

' a Animal  life. 
h Organic  life. 


•-1 

J -f! 
W .£ 

o .3 

. 

.-I  3 

CC 


2 and  3.  Nervous. 


4.  Arterial. 

5.  Venous. 

6.  Exhalant. 


7.  Absorbent. 

8.  Osseous. 

9.  Medullary. 


i Absorbent  vessels. 

( Absorbent  glands, 
j Bones  proper,  long,  flat,  and  short. 

\ Teeth. 

i Marrow  of  short  and  Hat  bones,  or  the  ends  of  long  bones. 
( Marrow  of  the  shafts,  or  bodies  of  long  bones. 


DIYISION  OF  THE  TEXTURES. 


9 


10.  C.4RTILAGINOUS. 


Ch 

w 


Articular  ends  of  movable  bones. 

Articular  surfaces  of  immovable  bones. 

Ribs,  Larynx,  Nasal  Partition,  &c. 
f Periosteum. 

Dura  Mater. 

Sclerotic. 

Albuginea. 

I Membrane  of  Kidneys,  Spleen,  &c. 
, i Scapulo-humeral  articulation. 
Fibrous  Capsules.  | ui/fe^oral  articulation. 

r,  ..  , i Palms  of  hand  and  foot. 
Partial.  | 

General.  Annular  ligaments. 
Enveloping. 


Proper  Fibrous 
Membranes. 


Fibrous  Sheaths. 


Aponeuroses. 


( at  By  broad  surface. 
< Arched. 

( y By  isolated  fibres. 


I 


f Simple. 

Tendons.  -< 

( Compound. 

r ■ ^ { Regularly  fasciculated, 

igamen  s.  j fasciculated. 


Membranous.  Fibro-cartilages  of  the 


Ears. 

Nose. 

Trachea. 

( Eyelids. 

A 1 ( Interarticular,  those  of  the  knee-joint,  lower  jaw. 

r icu  ar.  | Jjjt0j.yertebral  fibrocai'tilages. 

Tendinous. 

13  and  14.  (a  Animal  life,  all  the  voluntary  muscles. 

Muscular,  j h Organic  hfe,  e.  g.  heart,  stomach,  and  intestines. 

15.  Mucous,  comprehending  the  gastro-pulmonary  mucous  surface,  and  genito- 
urinary mucous  surface. 

16.  Serous,  comprehending  the  arachnoid  membrane,  pleura,  pericardium,  perito- 
nseum,  and  vaginal  coat. 

17.  Synovial. 

1 8.  Glandular,  comprehending  the  secreting  glands  only. 

1 9.  Dermoid  or  Cutaneous. 

20.  Epidermoid  or  Cuticular. 

21.  Pilous  or  Hairy. 


These  different  forms  of  animal  substance  he  considers  as  the 
organic  elements,  or  proximate  principles,  to  use  the  language  of 
chemistry,  into  which  animal  bodies  may  be  resolved.  These  ele- 
mentary tissues  he  again  refers  to  two  great  orders, — one  general- 
ly distributed  and  everywhere  present,  so  as  to  form  an  integrant 
part  of  every  other  animal  substance.  To  this  order,  which  he 
termed  general  or  generating  systems,  he  referred  cellular  mem- 
brane, arterial  and  venous  tissue,  the  nerves,  and  the  exhalants  and 
absorbents.  The  substances  of  the  second  kind,  which  are  placed 
in  determinate  situations,  and  confined  to  particular  regions,  con- 
sist of  the  bones,  cartilages,  fibrous  substances,  muscles,  and 
muscular  parts,  the  mucous,  serous,  and  synovial  membranes, 
glandular  organs,  the  skin  and  its  appendages,  the  nails,  hair,  &c. 


10 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


All  the  substances  of  this  latter  order  consist  of  a peculiar  matter, 
by  which  they  are  distinguished,  and  more  or  fewer  of  the  general 
tissues. 

As  the  structure  and  properties  of  the  same  elementary  tissue 
are  nearly  the  same  in  whatever  region  of  the  body  it  is  found,  or 
undergo  only  such  modifications  as  its  peculiar  use  or  local  con- 
nections render  requisite,  a just  idea  of  the  structure  of  the  human 
body  suggests  the  propriety  of  considering  the  extent,  disposition, 
structure,  and  most  obvious  properties,  mechanical  and  vital,  of 
each  tissue  by  itself.  The  examination  of  these  circumstances  con- 
stitutes the  subject  of  his  General  Anatomy,  a work  which,  in  ori- 
ginality of  plan,  and  general  excellence  of  performance,  notwith- 
standing occasional  defects  and  errors,  has  not  yet  been  surpassed. 

The  arrangement,  however,  of  Bichat  has  been  found  incorrect 
or  inconvenient ; and  various  alterations  or  modifications  of  it  have 
been  proposed  by  subsequent  authors.  The  first  which  we  shall 
notice  is  that  proposed  by  Dupuytren  and  Richerand,  which  has 
been  generally  esteemed  in  France  as  more  correct  and  compre- 
hensive. It  may  be  exhibited  in  the  following  tabular  form  : — 


1.  Cellular. 

2.  Vascular, 

3.  Nervous, 

4.  Osseous. 

5.  Fibrous, 

C.  Muscular, 

7.  Erectile. 

8.  Mucous. 

9.  Serous. 

10.  Horny  or  Epidermal, 

11.  Parenchymatous, 


( Arterial. 

< Venous. 

( Lymphatic. 

I Cerebral, 
j Gangliar. 

( Fibrous. 

< Fibro  cartilaginous. 
( Dermoid. 

i Voluntary. 

\ Involuntary. 


( Pilous. 

( Epidermal, 
i Parenchymatous. 
( Glandular. 


In  this  enumeration  several  important  differences  from  that  of 
Bichat  will  be  recognized.  It  presents  altogether  nineteen  sepa- 
rate tissues,  of  which  five  are  so  decidedly  peculiar,  that  they  do 
not  admit  of  being  associated  with  any  similar,  and  consequently 
form  distinct  systems  by  themselves ; while  the  other  fourteen  are 
referred  to  the  general  heads  of  vascular,  nervous,  fibrous,  muscu- 
lar, horny,  or  parenchymatous  systems.  The  result  of  this  ar- 
rangement is  to  diminish  the  number  of  organic  systems  from 


DIVISION  OF  THE  TEXTURES. 


11 


twenty-one  to  eleven,  one  of  which,  the  erectile,  comprehending  the 
peculiar  structure  of  the  cavernous  body,  the  clitoris,  the  nipple, 
and  the  spleen,  is  not  found  in  the  original  arrangement  of  Bichat, 
hut  has  been  added  by  MM.  Dupuytren  and  Richerand. 

A less  neat  and  elegant  arrangement  is  that  given  by  Hippoly- 
tus  Cloquet,  who  admits  in  the  human  body  the  following  fifteen 
tissues:  1.  The  cellular;  2.  The  membranous;  3.  The  vascular, 
including  blood-vessels,  and  lymphatics;  4.  Bone;  5.  Cartilage; 
6.  Fibro- cartilage ; 7.  Ligament;  8.  Muscle;  9.  Tendon;  10. 
Aponeurosis,  or  fascia;  11.  Nerve;  12.  Glandular  structure;  13. 
Follicle;  14.  Lymphatic  ganglion,  or  gland;  15.  The  Viscera. 
It  is  evident  that  the  last  mentioned  term  is  greatly  too  vague,  and 
that  the  structure  which  it  is  intended  to  denote  may  be  either 
united  with  several  of  those  already  noticed,  or  is  so  different  or 
opposite  in  different  situations,  that  admitting  it  as  a separate  tis- 
sue becomes  of  no  use  whatever  in  a correct  classification. 

N ot  unlike  to  the  arrangement  of  MM.  Richerand  and  Dupuy- 
tren is  that  proposed  by  John  Frederic  Meckel,  who  looked  on  the 
arrangement  of  Bichat  as  too  detailed,  and  embarrassed  with  toa 
many  and  minute  distinctions.  According  to  this  anatomist,  the 
medullary  system  should  be  united  with  the  cellular ; the  synovial 
should  be  viewed  as  a modification  of  the  serous  system ; the  pilous 
and  epidermal  systems  ought  not  to  be  separated  from  the  cutane- 
ous or  dermal ; and  even  this  last,  along  with  the  glandular  and  mu- 
cous, ought  to  be  referred  to  the  same  general  head.  According 
to  these  principles  all  the  organized  substances  composing  the  hu- 
man body  are  referred  by  iMeckel  to  the  following  ten  heads : — 


Against  this  arrangement  Mayer,  professor  of  anatomy  at  Bonn, 
has  urged  the  following  objections : — That  it  is  impossible  to  con- 
sider the  scarf-skin,  or  cuticle,  and  the  hairs,  as  of  the  same  or  si- 
milar structure  with  the  cutaneous  tissue  in  general : that  glandu;- 
lar  structure  cannot  be  regarded  as  pertaining  to  the  same  order 
with  the  mucous  membranes ; that  the  fibro-cartilages  ought  nei- 
ther  in  this  arrangement  nor  in  that  of  Bichat  to  be  considered  as 
distinct  from  cartilage  ; and  that  in  both  several  parts  of  the  ani- 


1.  Mucous,  or  cellular. 


6.  Fibro-cartilaginous. 

7.  Fibrous. 

8.  Muscular. 

9.  Serous. 

10.  Cutaneous. 


2.  Vascular. 

3.  Nervous. 

4.  Osseous. 


o.  Cartilaginous. 


12 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


mal  body  are  omitted,  or  can  have  no  convenient  place  of  refer- 
ence. Mayer  therefore  reduces  the  twenty-one  tissues  of  Bichat  to 
seven,  and  adds  an  eighth,  comprehending  the  crystalline  lens,  the 
cornea,  epidermis,  hair,  nails,  &c,  to  which  he  gives  the  general 
name  of  lamellar  tissue.  The  classification  of  organic  tissues  given 
by  this  anatomist  would  stand  in  the  following  order: — * 


I.  Lamellar. 


( Crystalline  lens.  Cornea. 

Cuticle. 

Hair,  nails  in  whatever  form,  as  claws,  bill,  hoof. 
Horns,  scales,  &c. 

I Teeth. 


II.  Filamentous. 
Cellular. 


1.  Cellular  system, 

2.  Adipose  system, 

3.  Medullary  system, 

4.  Serous  system, 

5.  Synovial, 

6.  Vascular, 

7.  Dermoid, 

8.  Mucous, 


f 1.  Cellular  system,  S,  Cellulosum. 

S.  Adiposum. 

Medullare. 

Serosum. 

Synoviale. 

Vasculosum. 

Dermodeum. 

Alucosum. 

9.  Structure  of  the  womb  and  reservoirs  of  secreted 
fluids.  Uterus. 

1.  Hard  membrane,  Dura  meninx.  Dura  mater. 

2.  Periosteum. 

3.  Cartilage. 

4.  Proper  membrane  of  intestinal  tube,  T.  Nervosa. 

5.  Membrane  of  synovial  capsules. 

TIL  Fibrous.  -{  6.  Ligaments. 

7.  Sheaths,  Vaginae  tendinum. 

8.  Aponeurosis,  Fascia. 

9.  T'endon. 

10.  Neurilema. 

11.  Soft  membrane,  Meninx  tenuis,  Pia  mater. 

To  these  may  be  added  a series  of  parts  pertaining  at  once  to  the  fibrous  and  the 
filamentous  cellular  system,  since  their  structure  presents  a predomination  of  fibrous 
filaments.  These  are, 


1.  The  Sclerotic. 

2.  The  Tunica  albuginea  of  the  testicle. 

3.  The  Proper  tunic  of  the  spleen  and  kidneys. 

4.  The  Cellulo-fibrous  sheath  of  conglomerate  and  conglobate 

glands. 

5.  The  Corpus  cavernosum  and  C.  spongiosum. 


IV.  Cartilaginous. 

V.  Osseous. 

1.  Lymphatic  ganglion  or  glands. 

VI.  Glandular.  2.  « Granular  glands,  or  those  provided  with  excreting  duct,  the 
lacrymal  gland,  the  salivary  glands,  the  pancreas,  liver, 
kidneys. 

ji  Glandular  organs  without  excreting  duct,  as  the  spleen,  thy- 
mus, renal  capsules. 

These  three  forms  of  glandular  organs  are  considered  by  Professor  Mayer  as  combi- 
nations of  minute  lympihatics,  or  blood-vessels,  or  both  united. 

VII.  MuscuL.iR.  1.  Animal  or  voluntary. 

2.  Organic  or  involuntary. 

VIII.  Nervous. 


* Sur  ITIistoIogie,  avec  une  division  nouvelle  des  tissus  du  corps  humain.  Par  le 
Docteur  Mayer,  Prof.  d’Anatomie  et  de  Physiologie.  Bonn,  1819. — Journal  de  Me- 
decine,  &c.  Vol.  XII.  193,  XII.  99. 


DIVISION  OF  THE  TEXTURES. 


13 


This  arrangement,  which  is  undoubtedly  very  elaborate,  and  per- 
haps more  comprehensive  than  either  that  of  Bichat  or  any  other 
author,  is  not,  however,  quite  faultless.  It  may  be  doubted  whe- 
ther the  lens  is  an  organic  body  at  all,  and  it  is  certainly  much  less 
an  organic  substance  than  the  cornea,  with  which  it  is  arranged. 
Cellular  and  cutaneous  tissue  are  certainly  not  so  similar  as  to  ad- 
mit of  being  referred  to  the  same  rank ; and  the  organs  destined 
to  contain  secreted  fluids  are  so  opposite  and  different  in  structure, 
that  it  appears  rather  violent  to  connect  them  in  one  group.  The 
proper  membrane  of  the  intestinal  tube  is,  according  to  the  result 
of  my  observations,  nothing  but  the  corion  of  the  villous  mem- 
brane ; at  least  I cannot  conceive  any  other  part  to  which  the  de- 
scription will  apply ; and  surely  the  soft  cerebral  membrane  {jpia 
mater)  cannot  justly  be  associated  with  such  substances  as  liga- 
ments, tendons,  or  aponeurotic  sheaths. 

The  system  termed  glandular  by  Professor  Mayer  is  still  more 
awkwardly  situate.  For  not  only  is  it  doubtful  with  what  justice 
the  lymphatic  glands  are  associated  with  the  proper  secreting  glands, 
but  the  latter  are  themselves  much  varied  in  structure  and  anato- 
mical characters ; and  as  to  the  old  notion  of  glandular  structure 
being  merely  an  expansion  of  vessels  arranged  in  a peculiar  man- 
ner, I fear  that  is  not  only  too  general  to  be  true,  but  that  there  is 
no  tissue  in  the  human  body  which  might  not  be  defined  in  the 
same  manner. 

In  the  formation  of  any  arrangement  of  the  organic  tissues  of 
which  the  human  body  consists,  two  extremes  must  be  sedulously 
avoided.  First,  care  should  be  taken  not  to  diminish  too  much 
the  number  of  individual  or  distinct  tissues,  and  to  avoid  the  use- 
less and  unnatural  system  of  referring  the  several  substances  em- 
ployed in  the  construction  of  the  human  body  to  a small  number 
of  general  heads.  This  was  the  error  of  the  ancient  physiologists, 
who,  from  a wish  to  simplify  more  than  nature  admitted,  referred 
the  various  animal  substances  to  an  elementary  fibre  or  fibres, 
which  they  imagined  formed  the  basis  or  ground-work  of  the  whole 
animal  organization. 

The  second  extreme  which  ought  to  be  avoided  in  this  matter  is 
the  practice  of  dividing  the  substances  of  the  animal  body  into  a 
greater  number  of  distinct  kinds  and  species  than  is  convenient  or 
necessary.  Very  superficial  inspection,  indeed,  shows  that  they  are 
not  the  same  either  in  anatomical  or  physical  characters,  or  in  che- 


14 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


niical  composition,  and  that  the  idea  of  considering  one  tissue  as  a 
modification  of  another,  or  one  animal  substance  as  forming  or  ge- 
nerating another,  is,  if  not  unnatural  and  impossible,  at  least  much 
more  remote  from  the  truth,  than  to  consider  them  as  actually  dif- 
fering in  kind,  and  possessing  the  properties  of  a separate  form  of 
organized  matter.  This,  therefore,  though  an  evil  in  its  way,  is 
one  of  much  less  injurious  consequence  than  the  former,  which,  by 
its  generalizing  spirit,  has  a tendency  to  supersede  investigation, 
and  to  consider  the  nature  of  the  animal  tissues  as  sufficiently  esta- 
blished. This  pei'haps  was  the  error  of  Bichat,  if  his  arrangement 
is  chargeable  with  fault.  But  with  still  greater  justice  it  may  be 
said,  that  the  recent  attempts  at  classification,  like  the  imperfect 
ones  of  the  ancient  physiologists,  are  to  be  blamed  in  diminishing 
too  much  the  number  of  separate  tissues,  and  in  delivering  arrange- 
ments, the  principles  of  which  are  more  general  and  comprehensive 
than  nature  warrants. 

It  may  indeed  be  assumed  as  a safe  principle,  that  all  the  sub- 
stances employed  in  the  construction  of  the  animal  body,  which  ara 
not  very  obviously  alike,  may  be  considered  as  separate  or  distinct 
proximate  principles,  till  careful  examination  shall  show  that  they 
ought  to  be  associated  with  others.  This  indeed  defeats  the  pur- 
pose of  classification,  which  is  useful  in  proportion  as  it  discovers 
genuine  analogies  and  general  resemblances  for  the  purpose  of 
communicating  knowledge  with  facility ; but  it  also  prevents  the 
approach  or  insinuation  of  error,  by  the  caution  with  which  it  ex- 
amines, and  the  discrimination  with  which  it  adopts. 

In  the  short  view  which  I propose  here  to  take  of  the  organic 
tissues,  I shall  not  adhere  scrupulously  to  either  of  those  arrange- 
ments which  I have  already  noticed,  but  attempt  to  modify  that  of 
Bichat,  which  is  perhaps  the  least  objectionable,  by  adopting  as 
many  of  the  suggestions  of  his  commentators  and  followers  as  the 
nature  of  the  subject  and  personal  observation  may  seem  to  autho- 
rize. In  the  course  of  this  exposition  I shall  have  frequent  occa- 
sion to  refer  to  the  best  and  most  complete  commentary  that  has 
yet  appeared, — that  by  Professor  Bedard,  who  has  availed  himself 
of  the  researches  of  J.  F.  Meckel,  and  Dr  J.  Gordon  of  Edinburgh, 
the  Prodrome  of  Mascagni,  the  Histologic  of  Mayer,  and  the  View 
of  Bock. 

The  human  body  consists  of  solid  and  fluid  substances,  the  for- 
mer of  which  are  organized,  and  determine  the  shape  of  the  body 


DIVISION  OF  THE  TEXTURES. 


15 


and  its  parts.  These  organized  solids  are  not  in  a strict  physical 
sense  solid  and  impenetrable.  Most  of  them  are  soft,  compressible, 
and  elastic,  by  reason  of  the  fluid  matter  contained  in  their  inter- 
stices; and  when  deprived  of  this  by  desiccation,  they  shrink  in 
various  degrees,  and  lose  both  bulk  and  weight.  The  general 
ratio  of  the  fluid  to  the  solid  parts  varies  from  7 to  1,  to  9 to  1. 
An  adult  carcass  weighing  perhaps  from  9 to  10  stones,  has  been 
reduced  by  desiccation  to  7^  lbs.  A human  body  may  be  reduced 
to  nearly  the  weight  of  its  skeleton,  which  varies  from  150  ounces 
= 9f  lbs.  to  200  ounces  = 12^  lbs. 

These  organized  solids  agree  in  the  possession  of  certain  gene- 
ral characters.  Their  internal  structure  consists  of  a union  of 
solid  and  liquid  matter,  which  is  observed  to  exude  in  drops  more 
or  less  abundant  from  the  surface  of  sections.  The  solid  parts  are 
generally  arranged  in  the  form  of  collateral  lines,  sometimes  ob- 
lique, sometimes  perfectly  parallel,  sometimes  mutually  intersect- 
ing. Such  lines  are  denominated  fibres^  and  occasionally  filaments. 
In  other  instances  the  solids  are  observed  to  consist  of  minute  glo- 
bular or  spheroidal  particles,  which  are  shown  by  the  microscope 
to  be  cells  or  membranous  cavities  with  a central  nucleus,  connect- 
ed generally  by  delicate  filaments.  Most  of  these  solids  anatomists 
and  microscopical  observers  have  attempted  to  resolve  into  what  they 
conceive  to  be  an  ultimate  fibre  or  last  element ; but  this  inquiry 
leads  beyond  the  bounds  of  strict  observation. 

Most  of  the  solids  may  be  demonstrated  to  be  penetrated  by  mi- 
nute ramifying  tubes  or  blood-vessels,  which  traverse  their  sub- 
stance in  every  direction,  and  in  which  is  contained  the  greater 
part,  perhaps  the  whole,  of  the  fluid  matter  found  in  the  solids. 
In  a few,  in  which  i-amifying  vessels  cannot  be  positively  demon- 
strated, their  existence  is  inferred  by  analogy  from  those  in  which 
they  can.  The  filamentous,  fibrous,  or  globular  or  cellular  ar- 
rangement, with  the  distribution  of  arborescent  vessels,  constitutes 
organization.  Tbe  substances  so  constructed  are  named  organized 
tissues  {tela,  textus,)  or  textures,  or  simply  tissues. 

The  organized  solids  also  resemble  each  other  in  chemical  con- 
stitution. They  may  be  resolved  into  proximate  principles,  either 
the  same  or  very  closely  allied.  The  proximate  principles  most 
generally  found  are  albumen,  fibrin,  and  gelatine,  one  or  other 
of  which,  sometimes  more,  form  the  basis  of  every  tissue  of  the 
human  body.  Next  to  these  are  mucus,  and  oily  or  adipose  mat- 
ter. Osmazome  or  extractive  matter  is  found  in  certain  tissues. 


IG 


GENERAL  AND  PATHOLOGICAL  ANATOMY, 


And  lastly,  several  saline  substances,  as  phosphate  of  lime,  carbo- 
nate of  lime,  soda,  hydrochlorate  of  soda,  are  found  in  variable 
proportions  in  most  of  them.  Of  these  principles  albumen  and 
fibrin,  which  are  closely  allied  and  pass  into  each  other,  are  the 
most  common  and  abundant.  Osmazome,  which  is  probably  a mo- 
dification of  fibrin,  is  less  frequent.  These  also  are  contained  in 
the  blood,  and  are  derived  from  that  fluid.  Gelatine,  though  not 
found  in  the  blood,  is  nevertheless  a principle  of  extensive  dis- 
tribution, being  found  in  skin,  cellular  tissue,  tendon,  cartilage, 
and  bone.  These  proximate  principles  are  resolved,  in  ultimate 
analysis,  into  carbon,  oxygen,  hydrogen,  azote,  phosphorus,  and 
sulphur.  From  the  saline  substances,  calcium,  potassium,  sodium, 
chlorine,  iron,  and  manganese  may  be  obtained. 

Mulder  maintains  the  existence  of  another  element  named  pro- 
teine,  obtained  by  a particular  process  from  albumen.  Its  cha- 
racter is  that  it  is  a common  element  to  albumen,  fibrin,  and  various 
of  the  elements  of  the  tissxies. 

The  different  organized  solids  which  enter  into  the  composition 
of  the  human  body  may  be  referred  to  the  following  seventeen 
simple  tissues.  Filamentous  or  cellular  tissue,  including  the  or- 
dinary cellular  membrane  and  adipose  membrane ; artery,  vein, 
with  their  minute  communications,  termed  capillary  vessels,  and 
the  erectile  vessels ; lymphatic  vessel  and  gland ; nerve,  plexus, 
and  ganglion ; brain  ; muscle  ; white  fibrous  system,  including  li- 
gament, periosteum,  and  fascia;  yellow  fibrous  system,  including 
the  yellow  ligaments,  &c. ; bone  and  tooth  ; gristle  or  cartilage  ; 
fibro-cartilage ; skin  ; mucous  membrane  ; serous  membrane  ; sy- 
novial membrane ; compound  membranes,  for  instance  the  fibro- 
mucous,  and  fibro -serous ; and  lastly,  the  peculiar  matter  which 
forms  the  liver,  the  kidneys,  the  female  breast,  the  testicle,  and 
other  organs  termed  glands.  To  these  may  be  added  the  compound 
textures  or  organs ; in  which  two  or  more  simple  textures  are 
united ; as  the  heart  and  lungs ; the  larynx  ; the  stomach,  duodenum^ 
and  alimentary  canal ; the  bladder,  prostate  gland,  and  penis ; 
and  the  female  organs  of  generation,  as  the  uterus,  ovaries.  Fal- 
lopian tubes,  and  vagina  with  appendages. 

These  tissues  may  be  distinguished  into  orders,  according  to  the 
mode  of  their  distribution  in  the  animal  frame.  Several,  for  in- 
stance filamentous  tissue,  artery  and  vein,  lymphatic  vessel,  and 
nerve,  are  most  extensively  distributed,  and  enter  into  the  compo- 


DIVISION  OF  THE  TEXTURES. 


17 


sition  of  all  the  other  simple  tissues.  To  these,  therefore,  which 
are  named  by  Bichat  general  or  generating  systems,  the  character 
of  textures  of  distribution  may  be  applied.  A second  order,  con- 
sisting of  substances  confined  to  particular  regions  and  organs,  and 
placed  in  determinate  situations,  viz.  brain,  muscle,  white  fibrous 
system,  yellow  fibrous  system,  bone,  cartilage,  fibro-cartilage,  and 
gland,  may  be  denominated  particular  tissues.  To  a third  order, 
consisting  of  substances  which  assume  the  form  of  a thin  mem- 
brane, expanded  over  many  different  tissues  and  organs,  may  be 
referred  skin,  mucous  membrane,  serous  membrane,  and  synovial 
membrane,  under  the  denomination  of  enveloping  tissues.  It  may 
indeed  be  objected,  that  the  circumstance  of  mechanical  disposition 
is  insufficient  to  communicate  a distinctive  or  appropriate  character, 
and  several  of  the  tissues  referred  to  the  second  head,  e.  g.  fascia., 
must,  on  this  principle,  be  referred  to  the  third.  The  objection  is 
not  unreasonable.  But  it  may  be  answered,  that  it  is  almost  vain  to 
expect  an  arrangement  entirely  faultless ; and  the  present  is  con- 
venient in  being  on  the  whole  more  natural,  and  therefore  more 
easily  remembered,  than  any  other.  A distinct  idea  of  it  may  be 
formed  from  the  following  tabular  view. 


General 

or 

Common 

Tissues. 


Particular 

Tissues. 


Enveloping 

Tissues. 


Compound 

Organs. 


Filamentous  Tissue. 
Artery. 

Vein. 


Capillary  VesseL 


I Lymphatic  Vessel. 

I IS  erve. 

' Brain. 

Muscle. 

White  Fibre. 

Yellow  Fibre. 

Bone. 

Cartilage. 

Fibro-Cartilage. 

L Gland. 

iSkin. 

Mucous  Membrane. 
Serous  Membrane. 
Synovial  Membrane. 

' 

Organs  of  Digestion. 

Organs  of  Respiration 
and  Circ'ilation. 

- Organs  of  Urinary  Ex- 
cretion and  Reproduc- 
tion. 

Organs  of  Sensation. 


( Ligament. 

^ Periosteum.' 
t Fascia. 

j Yellow  Ligaments, 
j Ligamentum  Nuchae. 
Tooth. 


1 Tongue,  GSsophagus, 

< Stomach,  Duodenum, 
( Ileum,  and  Colon. 

i Larynx,  Trachea,  Lungs, 
( and  Heart. 

1 Ureter,  Bladder,  Penis, 

< &c.  Uterus,  Ovaries, 
( Fallopian  Tubes. 

( Eye  ; Nasal  Passages  ; 

< Ear  ; Tongue,  and 
( Palate. 


B 


18 


GENERAL  AND  PATHOLOGICAL  ANATOIHY. 


CHAPTER  II. 

THE  FLUIDS  OF  THE  HUMAN  BODY. 

Section  I. 

The  solid  or  organized  textures  contain  fluids,  some  for  pur- 
])Oses  within  the  system,  others  destined  to  be  expelled  from  it.  I 
shall  give  a short  account  of  the  characters  and  properties  of  the 
principal  fluids  of  the  body,  preparatory  to  a view  of  their  morbid 
states. 

The  fluids  of  the  animal  body  are  various,  but  may  be  distin- 
guished into  three  sorts;  the  circulating  nutritious  fluid  named 
the  blood,  the  fluids  which  are  incessantly  mixed  with  the  blood  for 
its  renewal,  and  those  which  are  separated  from  it  by  secretion. 

The  blood  is  well  known  to  be  a viscid  liquid,  of  red  colour, 
peculiar  odour,  and  saline,  something  nauseous  taste.  Its  tempe- 
rature in  the  living  body  is  about  97° ; its  specific  gravity  is  about 
105  to  water  as  100.  Its  quantity  is  in  the  adult  considerable, 
varying  from  8 or  10  to  80  or  100  pounds;  the  average  is  about 
30  pounds. 

According  to  the  results  of  microscopic  observation,  it  consists 
of  red  particles  suspended  in  a serous  or  sero-albuminous  fluid. 
On  the  shape  of  these  red  particles  various  opinions  have  been  main- 
tained. Generally  represented  as  globular,  Hewson  describes  them 
as  flattened  spheroids,  or  lenticular  bodies,  a view  which  is  con- 
firmed by  the  observations  of  Prevost  and  Dumas,  Bedard,  of 
Plodgkin  and  Lister,  and  Mr  Wharton  Jones.  The  opinion  of 
Home  and  Young,  that  the  flattening  of  these  globules  is  a process 
posterior  to  the  discharge  of  the  fluid,  is  not  improbable.  These 
particles  have  since  the  time  of  Hewson  been  almost  universally 
represented  as  consisting  of  a central  transparent  whitish  globule, 
inclosed  in  a red  translucent  vesicle,  which  gives  them  the  shape  of 
an  oblate  spheroid.  In  man  and  the  mammalia  they  are  circular 
discs,  often  with  a depression  on  the  sides.  The  diameter  of  these 
particles  is  estimated,  by  the  subdivided  scale  of  Kater,  the  mi- 
crometer of  Wollaston,  and  the  eriometer  of  Young,  at  j-ggo? 
by  the  common  micrometer,  at  Tygg  of  an  inch.  {Phil.  Trans.) 
Mr  Gulliver  estimates  the  average  thickness  of  the  human  blood- 


FLUIDS  OF  THE  HUMAN  BODY. 


19 


col’puscle  at  islooth  part  of  an  English  inch,  and  the  diameter  at 
^ioo'  This  description  applies  to  the  blood  circulating  in  the  ves- 
sels. 

The  flattening  of  the  corpuscles  is  greatest  in  reptiles,  amphibia, 
and  Ashes ; and  it  is  most  remarkable  in  the  salamander.  In  birds 
the  red  globules  are  flattened,  but  in  less  degree  than  in  the  am- 
phibia. 

The  red  particles  are  largest  in  the  amphibia.  In  birds,  rep- 
tiles, and  Ashes  they  are  smaller.  In  mammalia  they  are  smallest. 
(Gulliver  apud  Hewson,  p.  236.) 

Discharged  from  the  vessels,  it  exhales,  during  the  process  of 
cooling,  a thin  watery  vapour,  consisting  of  water  suspending  ani- 
mal matter  capable  of  impressing  the  sense  of  smell,  and  under- 
going decomposition.  During  the  same  space  it  is  observed  to  be 
converted  into  a Arm  mass,  which,  though  still  soft  and  elastic,  is 
entirely  void  of  fluidity.  As  this  process  advances,  a thin  watery 
fluid,  straw-coloured,  not  perfectly  transparent,  is  observed  to  ex- 
ude from  every  part  of  the  solid  mass,  which  also  diminishes  in 
size,  till  at  length  it  is  found  floating  like  a tolerably  thick  cake  in 
the  thin  watery  fluid.  The  thick  solid  mass  is  named  the  clot  or 
coagulum  ; the  watery  fluid  is  denominated  serum  ; and  the  process 
of  the  separation,  which  is  spontaneous,  is  termed  coagulation.  The 
blood  at  the  same  time  is  said  to  discharge  carbonic  acid. 

The  clot,  if  divided  and  washed  in  water  often  changed,  or  in 
alcohol  or  aqua  potassce,  may  be  deprived  of  its  red  colour,  and 
made  to  assume  a gray  or  bluish-white  tint.  This  gray  mass, 
which  is  tough,  coherent,  opaque,  and  more  or  less  dense,  homo- 
geneous, but  void  of  traces  of  organic  structure,  consists  chiefly  of 
albumen  or  flbrin,  or  a substance  partaking  of  several  of  the  cha- 
racters of  both.  To  this  substance  the  blood  owes  its  viscidity  and 
its  property  of  spontaneous  coagulation ; and  from  the  circumstance 
of  its  resemblance  to  the  lymph  or  albuminous  fluid  which  is  effused 
from  wounds  and  inflamed  surfaces,  and  to  the  fibrin  of  muscle,  and 
tbe  albumen  of  many  of  the  tissues,  it  may  be  regarded  as  the  most 
vital  and  nutritious  part  of  that  fluid.  It  is  a mistake,  neverthe- 
less, to  assert,  as  is  done  by  Bedard  and  others,  that  this  substance 
presents  to  the  microscope  the  aspect  and  structure  of  muscular 
fibre.  Its  aspect  is  by  no  means  so  regular  as  this,  nor  can  its  par- 
ticles be  said  to  present  traces  of  organic  structure  or  arrangement. 

The  red  matter  removed  by  washing  is  a mixture  of  serum,  of 
globules,  and  of  a peculiar  colouring  matter.  Modern  chemistry 


20 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


shows  that  the  latter  is  a paiticular  substance,  insoluble  in  water, 
but  susceptible  of  suspension  in  it  to  an  extreme  extent,  and  con- 
sisting of  animal  matter  combined  with  peroxide  of  iron.  It  is 
distinguished  by  the  name  of  zoohematine.  Deprived  of  this,  the 
globules  are  estimated  by  Bauer  at  g of  inch  in  diameter. 

The  serum,  with  the  taste  and  odour  of  the  blood,  rather  alka- 
line, coagulates  at  162°  F.  or  on  the  addition  of  acids,  nitrate  of 
silver,  or  corrosive  sublimate,  and  then  resembles  boiled  white  of 
egg.  The  coagulated  matter  is  albumen  ; and  a little  water  con- 
taining soda  and  salts  of  soda  may  be  separated.  It  is  a remark- 
able difference  between  this  albumen,  which  is  suspended  in  the 
serum,  and  that  which  constitutes  the  clot,  that  while  the  former 
requires  heat  as  a re-agent,  the  latter  assumes  the  solid  form  spon- 
taneously. 

The  proportion  of  serum  to  clot  varies  in  different  animals,  in 
different  individuals,  and  in  different  states  of  the  system,  healthy 
and  morbid. 

In  the  human  body  a quantity  of  five  ounces  of  blood  usually  fur- 
nishes about  one  ounce  and  two  drachms,  or  one  ounce  and  four 
drachms  of  serum.  In  inflammatory  diseases  the  amount  of  the  se- 
rum is  usually  increased.  Thus  in  acute  rheumatism  and  in  pneu- 
monia, if  the  huffy  coat  be  thick  and  strong,  the  serum  afforded  by 
five  ounces  amounts  to  one  ounce  and  six  drachms,  or  two  ounces. 
In  fever,  again,  the  proportion  of  serum  is  diminished.  Thus  five 
ounces  of  blood  will  afford  not  more  than  one  ounce,  or  only  six 
drachms  of  serum.  At  advanced  periods  of  the  disease,  for  in- 
stance after  the  first  eight  days  or  towards  the  close  of  the  first  sep- 
tenary period,  the  serum  afforded  by  five  ounces  is  not  more  than 
six  or  four  drachms ; and  in  some  instances  it  is  about  three  drachms 
or  two  drachms,  or  not  more  than  one  and  a half. 

In  these  circumstances  the  clot  is  less  firm  than  usual,  and  is 
loose  and  flabby. 

In  purpura  most  commonly  no  serum  is  separated ; and  the  clot 
appears  alone  as  a mass  of  gelatinised  blood  imperfectly  coagulated. 

These  phenomena  depend  on  the  degree  of  the  coagulating 
power ; and  they  may  be  taken  to  measure  its  force.  Thus  in  the 
healthy  state,  and  in  certain  inflammatory  diseases,  the  coagulating 
power  is  greatest.  In  fever  the  coagulating  power  is  weakened  in 
proportion  as  the  disease  advances.  And  in  purpura  and  at  the 
close  of  fever  the  coagulating  power  is  very  nearly  null. 

This,  however,  is  merely  the  relation  of  the  serum  to  the  clot. 


FLUIDS  OF  THE  HUMAN  BODY. 


21 


when  under  spontaneous  coagulation.  After  this  is  completed,  the 
clot  still  retains  so  much  serum,  that  it  must  be  subjected  to  re- 
peated pressure,  or  to  evaporation,  or  both,  before  the  clot  can  be 
obtained  in  a solid  and  dry  state,  quite  free  from  serum.  When  this 
has  been  done,  it  is  found  that  the  spontaneously  coagulable  part 
of  the  blood  is  always  much  less  than  the  fluid  part ; in  other  words, 
that  it  is  in  the  ratio  of  minority  to  the  serum,  or  numerically  in 
the  ratio  of  13  to  87  in  100  parts  of  blood. 

Liquid  fibrin,  or  the  spontaneously  coagulable  part  of  the  blood, 
is  most  abundant  in  warm-blooded  animals  ; and  among  these  it  is 
more  abundant  in  the  blood  of  birds  than  in  that  of  the  mammalia. 
In  fishes  it  is  very  scanty  ; and  it  is  sparing  also  in  the  blood  of  the 
reptile  family.  In  fishes  and  reptiles  it  is  more  in  the  form  of  a 
liquid  gore,  viscid  and  semifluid,  but  scarcely  coagulating,  than  in 
that  of  blood. 

It  is  a well-known  fact  that  in  frogs  the  blood  does  not  coagu- 
late on  exposure  of  the  vessels  to  air,  as  it  does  in  the  mammalia. 
This  must  be  owing  either  to  the  blood  of  these  animals  containing 
a much  smaller  proportion  of  fibrin  than  that  of  the  mammalia,  or 
the  fibrin  having  much  less  coagulating  power.  In  either  case  it 
comes  to  the  same  result. 

This  has  been  supposed  by  De  Saissy  and  others  to  bear  some 
relation  to  the  state  of  respiration  in  these  several  classes ; and  the 
idea  seems  accordant  with  the  facts.  In  birds  the  function  of  re- 
spiration is  most  fully  developed.  In  reptiles  and  fishes  it  is  very 
imperfectly*  developed. 

When  blood  drawn  from  the  veins  of  a person  labouring  under 
acute  rheumatism  and  other  inflammatory  diseases  is  undergoing 
coagulation  in  a glass  vessel,  a colourless  fluid  may  be  perceived 
round  the  edge  of  the  surface  ; and  after  anhnterval  of  four  or  five 
minutes,  a bluish  appearance  is  observed,  forming  an  upper  layer 
of  the  blood,  in  consequence  of  the  subsidence  of  the  red  particles 
to  a certain  distance  below  the  surface,  and  the  clear  liquor  being 
left  between  the  place  of  the  red  particles  and  the  edge  of  the  ves- 
sel. This  liquid  may  be  collected  by  a spoon  and  placed  in  another 
vessel,  where  it  is  first  clear,  though  opalescent,  viscid,  and  homo- 
geneous. After  some  time,  however,  it  undergoes  separation  into 
two  parts ; one  coagulated,  the  other  fluid.  The  coagulated  part  is 
the  fibrin  of  the  blood  or  that  which  is  spontaneously  coagulable ; 
the  fluid  part  the  serum.  The  opalescent  liquor  has  been  named 
liquor  sanguinis,  (Babington.) 


22 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Gmelin,  Chevreul,  and  Lecanu  obtained  from  the  blood  stearine 
and  elaine. 

The  colour  of  the  blood  varies  in  different  parts  of  the  system. 
In  the  left  auricle,  ventricle,  and  arterial  trunks  generally,  its  co- 
lour is  bright  scarlet,  a tint  which  it  loses  in  the  capillary  vessels. 
In  the  veins,  venous  trunks,  right  auricle,  right  ventricle,  and  pul- 
monary artery,  its  colour  is  a dark  or  purple-red,  or  modena.  As 
it  moves  from  the  trunk  and  branches  through  the  minute  divisions 
of  the  pulmonai'y  artery,  it  gradually  parts  with  this  tint ; and  in 
the  branches  of  the  pulmonary  veins  it  is  found  to  have  acquired 
the  bright  scarlet  colour  which  it  has  in  the  left  auricle,  ventricle, 
and  aorta.  Hence  the  modena  or  dark-coloured  blood  is  distin- 
guished as  venous,  or  proper  to  the  veins ; and  the  bright  red  or 
scarlet-coloured  as  proper  to  the  arteries. 

In  the  foetus,  the  blood  contains  little  coagulable  matter ; and 
this  principle  is  entirely  wanting  in  the  blood  of  the  menstrual  dis- 
charge. 

The  fluids  received  by  the  blood  are  chyle  and  lymph.  Chyle 
is  derived  from  chyme,  a gray  pulpy  substance,  formed  from  the 
alimentary  mass  in  the  stomach  and  duodenum.  Detached  from 
this  substance,  and  received  by  the  chyliferous  tubes,  it  is  whitish 
and  scarcely  coagulable.  In  the  mesenteric  glands  it  becomes 
more  coagulable,  and  assumes  a rose  colour.  Lastly,  in  the  thoracic 
duct,  and  before  joining  the  mass  of  blood,  it  is  distinctly  rose-co- 
loured, coagulable,  and  globular  in  its  particles.  In  the  branches 
of  the  pulmonary  artery  it  appears  to  become  perfect  blood.  Lymph 
is  a colourless,  viscid,  albuminous  fluid,  imperfectly  known. 

Of  the  fluids  separated  from  the  blood,  all  cannot  be  said  to  be- 
long to  the  animal  body.  Several,  for  instance  the  perspired  fluid 
of  the  skin  and  lungs,  the  fluid  of  the  cutaneous  and  mucous  fol- 
licles, and  the  urine,  become,  after  secretion,  foreign  to  the  body, 
and  require  to  be  removed.  Those  belonging  to  the  body  are  such 
as  are  prepared  for  some  purpose  within  it,  and  after  this  are  either 
re-absorbed,  or,  being  decomposed,  are  expelled.  Of  the  former 
kind,  fat,  serum  of  serous  membranes,  and  synovia,  afford  examples. 
To  the  latter  description  belong  tears,  saliva,  pancreatic  fluid,  bile, 
the  seminal  fluid  of  the  male,  and  the  milk  of  the  female,  all  of 
which  are  the  result  of  a distinct  glandular  secretion  for  a specific 
purpose,  after  which  they  are  expelled  from  the  economy. 

The  urine,  though  also  the  result  of  glandular  secretion,  is  ne> 
vertheless  exempt  from  this  rule,  and  though  separated  from  arterial 


FLUIDS  OF  THE  HUMAN  BODY. 


23 


blood,  is  forthwith  eliminated.  Its  chief  purpose  seems  to  be  to  afford 
a convenient  vehicle  for  ridding  the  system  of  superfluous  azote,  and 
to  maintain  the  due  proportion  between  this  and  the  other  ultimate 
principles,  carbon,  hydrogen,  and  oxygen.  The  fluids  which  fulfil 
a purpose  in  the  economy  are  regarded  as  secretory,  and  are  re- 
markable  for  a predominance  of  alkali;  those  which  do  not,  are 
excrementitial,  and  are  generally  acid. 

Bile,  the  secreted  product  of  the  liver,  may  be  regarded  as  a 
choleate  of  soda  with  taurine ; both  containing  sulphur. 

Urine  may  be  regarded  as  urea  suspended  or  dissolved  in  water. 
Urea  is  the  peculiar  and  characteristic  element  of  the  secretion. 
It  contains  also  a little  uric  acid,  which  is  probably  produced  from 
the  urea,  as  it  can  scarcely  be  said  to  be  a constituent  of  healthy 
urine.  The  other  ingredients  are  saline  matters  common  to  the 
blood  and  the  urine,  or  complementary  between  these  fluids. 

The  density  of  healthy  urine  varies  from  1015  to  1033,  water 
being  as  1000 ; and  the  average,  as  determined  from  the  examina- 
tion of  the  urine  in  fifty  instances  of  persons  in  good  health,  is  at 
the  highest  1.026,  and  at  the  lowest  1017.  The  general  average, 
therefore,  amounts  to  1022.  If  it  he  stated  between  1022  and  1026 
it  cannot  be  far  wrong.  This  is  understood  while  the  quantity  dis- 
charged daily  is  from  45  to  53  ounces,  which  is  about  the  general 
average  in  healthy  individuals  who  consume  liquids  at  the  ordinary 
rate. 

This  density  above  that  of  water  urine  owes  to  the  presence  of 
urea  and  saline  matters.  If  the  urea  and  saline  matters  be  in- 
creased, the  density  of  the  urine  is  increased  ; and  if  they  be  di- 
minished, the  density  of  the  urine  is  also  diminished. 

It  may  be  here  observed  that  urea  is  the  form  which  the  elements 
of  the  fibro-albuminous  parts  of  the  blood  assume  after  these  fibro- 
albuminous  have  been  employed  in  repairing  the  waste  of  the 
tissues.  If  we  compare  the  proximate  chemical  principles  of  al- 
bumen with  those  of  urea,  we  shall  see  that  the  latter  are  the  com- 
plement of  the  former.  Thus 

Hydrogen.  Carbon.  Oxygen.  Azote. 

Albumen  consists  of  7.77  50.00  26.66  15.55 

Urea  consists  of  . 6.66  20.00  26.66  46.66 

Thus  while  albumen  and  urea  contain  the  same  proportion  of  oxy- 
gen, the  former  contains  one-seventh  more  hydrogen,  three-fifths 
more  carbon,  and  one-third  less  azote.  It  is  known  that  the  former 
proportions  are  employed  in  repairing  the  waste  of  the  albuminous 
tissues,  especially  the  muscular  system,  and  while  carbon  and  oxy- 


24 


GENERAL  AND  PATHOLOGICAL  AKATOMY. 


gen^are  discharged  by  the  lungs,  and  carbon,  oxygen,  and  hydro- 
gen by  the  liver,  the  large  superfluous  portion  of  nitrogen  not  re- 
quired is  left  in  the  form  of  urea,  to  pass  through  the  blood,  and 
by  means  of  the  kidneys  to  be  expelled  from  the  system. 

In  the  healthy  state  urine  is  always  acid  when  discharged.  It  is 
prone,  however,  to  undergo  the  putrefactive  decomposition ; and 
then  its  acid  reaction  disappears,  and  it  becomes  alkaline.  This 
change  is  much  favoured  if  not  wholly  occasioned  by  the  presence 
of  mucus,  purulent  matter,  or  other  azotized  substances ; for  if  the 
urine  be  filtered  so  as  to  remove  these  substances,  and  placed  in  a 
close  vessel,  secluded  from  the  air,  it  may  be  preserved  for  a long 
time  without  undergoing  change  or  presenting  any  odour  indicat- 
ing the  presence  of  decomposition. 

Section  II. 

A.  The  morbid  states  of  the  blood  are  mostly,  if  not  all,  connected 
with  morbid  states  of  the  system  at  large,  of  the  organs  of  respiration, 
or  the  organs  of  secretion.  The  most  important  are  the  following. 

1 . In  diseases  of  plethora  it  has  been  supposed  that  the  blood  is 
more  abundant  than  usual  in  quantity,  and  that  its  fibrine  is  in- 
creased in  proportion.  The  first  point  it  is  not  easy  to  deter- 
mine. The  fibrine,  however,  is  not  increased.  The  red  globules 
are  stated  by  Andral  to  be  the  only  element  in  which  an  increase 
actually  takes  place.  In  31  blood-lettings  he  found  for  the  medium 
the  cypher  141  in  1000,  127  in  1000  being  the  average  of  health; 
for  the  minimum,  131  ; and  for  the  maximum,  154.  There  is,  in 
short,  in  the  blood  of  the  plethoric  an  increased  amount  of  red  glo- 
bules, and  a great  deal  less  water  than  the  aveTage. 

. 2.  In  chlorosis,  dyspeptic  and  other  diseases  in  which  the  leading 
character  is  anaemia^  the  red  globules  are  diminished  in  propor- 
tion. Andral  found,  as  the  medium  of  the  cypher  for  the  globules 
in  fifteen  cases  of  incipient  anaemia,  the  number  1 09,  and  in  twenty- 
four  cases  of  confirmed  anaemia,  the  number  65.  In  spontaneous 
anaemia,  mild  or  violent,  the  globules  alone  are  diminished;  the 
fibrine  and  the  albumen  of  the  serum  preserving  their  normal  pro- 
portion. In  hemorrhagic  anaemia,  at  first  the  globules  only  are 
diminished.  But  if  the  morbid  condition  continue,  the  fibrine  and 
the  albumen  of  the  serum  are  also  diminished.  There  is  a form  of 
anaemia  which  may  be  called  toxic,  as  it  depends  on  the  influence 
of  the  mineral  poisons.  In  that  from  lead,  Andral  finds  that  the 


FLUIDS  OF  THE  HUSL4N  BODY. 


25 


red  globules  are  as  much  diminished  as  in  spontaneous  ansemia, 
while  the  fibrine  and  albumen  preserve  their  normal  proportions. 

In  chlorosis  it  is  a curious  fact  that  the  blood  is  occasionally 
buffy.  This  Andral  ascribes  to  the  circumstance,  that  in  these 
patients,  v.  hile  the  blood  loses  its  colouring  matter,  it  preserves  all 
its  fibrine.  It  must  be  observed,  nevertheless,  that  in  many  chlo- 
rotic patients,  processes  are  present  which  give  the  blood  the  ten- 
dency to  the  buffy  coat. 

It  is  also  to  be  observed  that  in  renal  dropsy  ofttimes,  while  the 
blood  is  deteriorated  by  diminution  of  red  particles,  and  while  the 
patient  is  pale  and  dropsical,  yet  blood  if  drawn  presents  the  huffy 
coat.  This  merely  shows  that  the  blood  is  altogether  in  an  unna- 
tural and  probably  diseased  condition.  The  textures  are  unable 
to  take  from  it  the  fibrine  which  they  do  in  the  healthy  state,  and 
hence  this  fibrine  remains  ready  to  be  separated  in  the  form  of 
buffy  coat. 

3.  State  of  the  blood  in  inflammatory  diseases. — In  inflammation  the 
blood  assumes  the  property  of  forming  what  is  called  the  buffy  coat, 
{tunica  coriacea).  This  consists  in  the  clot  presenting  at  its  surface  a 
covering  variable  in  thickness,  whitish-grey  in  colour,  and  of  con- 
siderable toughness.  In  the  slightest  degree  it  is  very  thin,  and  a 
mere  pellicle.  In  more  considerable  degrees  of  inflammation,  it  is 
thicker,  as  thick  as  a shilling  or  a half-crown  piece,  and  firm  and  te- 
nacious. In  the  most  intense  degree,  it  is  as  thick  as  a crown  piece 
or  a penny  piece  ; extremely  firm,  hollow  on  the  top  and  elevated 
at  the  edges ; and  being  contracted  from  the  circumference  to  the 
centre,  it  is  much  cupped.  This  condition  of  the  blood  is  most 
common  in  acute  rheumatism,  pneumonia,  pleurisy,  peritonitis,  he- 
patitis, disease  of  the  kidney,  the  early  stage  of  pulmonary  con- 
sumption, and  similar  disorders.  It  is  also  observed  during  preg- 
nancy. 

The  cause  of  the  buffy  coat  has  been  a subject  of  great  inquiry ; 
but  regarding  it  little  is  ascertained.  It  may  often  be  observed  in 
the  act  of  formation,  by  the  surface  of  the  blood  drawn,  as  it  is  co- 
agulating, assuming  a peculiar  bluish  colour,  which  is  evidently 
dependent  on  the  liquor  sanguinis  undergoing  spontaneous  coagu- 
lation, wliile  the  red  part  of  the  blood  subsides  from  it.  In  gene- 
ral the  blood  coagulates  more  slowly  in  inflammatory  diseases  than 
in  the  healthy  state.  But  the  rate  of  the  diminution  does  not  cor- 
respond to  the  amount  of  the  buffy  coat.  If,  however,  we  bear  this 
fact  in  remembrance,  that  when  it  takes  place  as  in  inflammatory 


26 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


diseases  and  in  pregnancy,  there  is  in  the  vessels  of  some  part  of 
the  body  a process  of  separating  fibrin  or  fluid  fibrin  in  the  shape 
of  lymph,  which  afterwards  undergoes  spontaneous  coagulation,  it 
may  be  regarded  as  most  probable,  that,  while  the  process  of  nor- 
mal nutrition,  that  is,  deposition  of  fluid  fibrin  in  the  different  tex- 
tures and  organs,  is  suspended  or  diminished,  the  albuminous  mat- 
ter which  ought  to  be  employed  in  this  process  is  left  free  in  the 
blood,  and  therefore  is  found  in  that  fluid. 

Buffy  blood  is  less  thick  than  healthy  blood ; but  its  liquor  san- 
guinis contains  more  fibrin.  The  red  globules  are  very  numerous, 
and  they  are  aggregated  rapidly  and  closely.  (W.  Jones,  Ed.  Med. 
and  Surg.  Journal,  lx.) 

In  fever,  and  especially  in  typhous  fever,  the  blood  loses  part  of 
its  spontaneously  coagulating  property.  The  serum  is  diminished 
in  quantity,  or  rather  is  not  separated  from  the  clot,  which  is  loose, 
flaccid,  and  commonly  dark-coloured,  and  as  it  were  semifluid. 

4.  Oil  in  the  blood. — In  certain  states  of  the  system  the  serum  is 
observed  to  he  turbid,  opalescent  in  colour,  and  not  unlike  milk. 
The  clot  is  then  in  general  of  a peculiar  pink  colour,  whether  from 
some  intrinsic  change,  or  the  optical  effect  of  the  milky  serum. 
This  state  of  the  serum  is  owing  to  its  being  mixed  with  fatty  mat- 
ter, or  rather  oil.  If  serum  of  this  kind  be  agitated  in  a phial  with 
a quantity  of  sulphuric  ether,  the  latter  dissolves  the  oil,  which 
is  after  some  time  found  floating  in  the  form  of  a clear  yellow  oil 
on  the  surface  of  the  serum,  which  is  then  clear  and  of  its  usual 
characters.  The  oil  may  be  then  withdrawn  by  the  pipette  or 
poured  off,  and  is  found  to  leave  on  paper  an  oleaginous  stain. 

This  state  of  the  blood,  which  was  originally  observed  by  Tul- 
pius,  Schenke,  Morgagni,  and  Hewson  and  several  of  his  friends,* 
and  afterwards  by  Dr  Traill,  Dr  Ziegler,  and  Dr  Christison,  takes 
place  in  various  wasting  diseases,  and  is  often  observed  in  granular 
degeneration  of  the  kidney.  The  oil  appears  to  be  mixed  with  the 
serum  in  the  form  of  an  emulsion.  It  is  most  usual  in  corpulent 
persons ; and  appears  especially,  or  has  been  noticed  mostly,  when 
they  are  attacked  by  disease.  It  is  connected  also  with  an  im- 
perfect state  of  digestion. 

5.  In  jaundice  and  various  diseases  of  the  liver,  even  in  inflamma- 
tion of  the  liver  affecting  the  lower  surface  of  the  organ  and  the 

* Experimental  Inquiries,  Part  the  First,  containing  an  Inquiry  into  the  Properties 
of  the  Blood,  with  Remarks  on  some  of  its  Morbid  Appearances.  3d  Edition.  By 
'VViliiam  Hewson,  F.  R.  S.  London,  1780.  Pp.  I9I. 

4 


FLUIDS  OF  THE  HUMAN  BODY. 


27 


vicinity  of  the  capsule  of  Glisson,  the  serum  occasionally  presents 
a considerable  proportion  of  bile.  It  is  then  of  a pale  green  colour ; 
and  on  the  addition  of  hydrochloric  acid,  it  undergoes  immediate 
coagulation,  with  the  formation  of  a bright  grass-green  precipitate. 

6.  Urea  is  found  in  the  blood  in  instances  of  granular  disease  of 
the  kidney,  and  those  cerebral  and  urinary  affections  in  which  the 
secretion  of  the  kidneys  is  suspended  or  suppressed.  It  may  be  de- 
tached from  the  serum  by  treating  the  latter  with  nitric  acid,  when 
crystals  of  nitrate  of  urea  are  found. 

7.  Purulent  matter  is  found  in  the  blood  in  certain  diseases  in 
which  suppuration  is  going  on  at  the  internal  surface  of  a membrane 
or  in  the  interior  of  an  organ.  The  most  usual  preceding  state, 
however,  is  inflammation  and  suppuration  of  a vein  or  veins,  and 
the  secondary  effects  thence  resulting,  especially  suppuration  with- 
in one  of  the  joints.  If  the  blood  in  cases  of  this  kind  be  inspect- 
ed under  the  microscrope,  it  is  observed  to  present  globules  of  puru- 
lent matter.  In  certain  forms  of  disease  of  the  spleen,  purulent 
matter  is  found  mixed  with  the  blood  in  the  veins  after  death,  to 
which  this  state  leads. 

B.  Of  chyle  and  lymph  the  morbid  states  are  too  little  known  to 
speak  of  them  with  certainty. 

C.  Of  the  morbid  changes  of  bile  also  very  little  is  known. 
During  the  process  of  digestion  it  is  decomposed ; at  least  in  the 
healthy  state  it  is  never  seen  pure  in  the  intestinal  discharges. 

The  bile  is  liable  to  be  formed  into  concretions  or  gall-stones, 
varying  in  size.  When  small  these  are  numerous ; when  large 
there  may  be  only  one  or  at  most  two.  A large  sized  gall-stone 
is  one  that  is  one  inch  or  more  in  diameter.  These  bodies  consist 
of  inspissated  bile,  cholesterine,  and  colouring  matter. 

D.  The  morbid  states  of  the  urine  are  manifold.  They  may  be 
referred  to  the  following  heads.  1.  Increase  in  the  proportion  of 
nitrogenous  matter,  e.  g.  urea  increased  in  quantity  generally  with 
formation  of  uric  acid  ; 2.  Diminished  cohesion  of  elements  of  urea ; 
3.  Increase  in  saline  matter ; and  4.  By  the  presence  of  new  sub- 
stances, as  albumen,  purulent  matter,  sugar,  &c. 

1.  The  first  and  most  usual  is  excess  of  urea,  generally  with  uric 
acid.  The  urine,  if  allowed  to  evaporate  in  a watch-glass,  one  or 
two  drops  of  nitric  acid  having  been  previously  poured  on  it,  pre- 
sents in  no  long  time  crystals  of  nitrate  of  urea.  At  the  same  time 
uric  acid  is  usually  deposited  fi’om  the  urine. 

2.  Another  form  of  disorder  consists  in  the  formation  of  urate  of 


28 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


ammonia.  The  uric  acid  being  formed  in  the  urine  as  in  the  last 
case,  it  is  probable  that  part  of  the  urea  itself  is  decomposed,  the 
nitrogen  and  hydrogen  combining  to  form  ammonia.  This  takes 
place  in  birds  and  serpents  at  all  times,  and  carnivorous  animals 
and  tbe  human  body  when  living  mostly  on  animal  food. 

3.  A form  more  intense  still  is  denoted  by  the  formation  of  carbo- 
nate of  ammonia.  There  can  be  little  doubt  that  when  this  pro- 
duct appeal’s,  it  is  the  result  of  the  spontaneous  decomposition  of 
the  urea ; the  carbon  and  oxygen  forming  carbonic  acid,  and  the 
nitrogen  and  hydrogen  ammonia. 

4.  A form  still  different  is  indicated  by  the  formation  of  phosphate 
of  ammonia  and  magnesia.  The  causes  and  the  mechanism  of  this 
production  are  not  well  known.  It  is  only  known  that  it  takes 
place  most  readily  under  a state  of  the  system  of  impaired  strength ; 
that  the  urine  is  either  not  acid  or  speedily  becomes  alcaline ; and 
that  the  urine  is  most  prone  to  the  putrefactive  decomposition.  As 
the  addition  of  ammonia  to  urine  causes  a precipitate  of  phosphate 
of  lime,  there  is  strong  reason  to  believe  that  the  urea  is  first  de- 
composed and  its  hydrogen  and  azote  made  to  furnish  ammonia, 
and  that  this  latter  substance  causes  the  precipitate  either  of  phos- 
phate of  lime  or  phosphate  of  magnesia  according  to  circumstances. 

5.  Other  morbid  products  are  purpuric  acid,  purpurate  of  am- 
monia, oxalate  of  lime. 

6.  Blood  may  be  contained  in  the  urine  either  in  consequence  of 
wounds  and  injuries  of  the  kidneys,  ureters,  bladder,  or  prostate 
gland,  or  in  consequence  of  calculi  in  any  of  these  parts,  or  inflam- 
matory and  hemorrhagic  diseases.  The  urine  is  either  like  blood, 
containing  a considerable  proportion  of  that  liquid,  or  it  is  only  of 
a dark  brown  colour,  coagulable  by  heat  or  acids,  and  presenting 
to  the  microscope  blood-globules.  The  physician  has  most  fre- 
quent occasion  to  see  it  in  the  latter  state;  and  sometimes  the  urine 
is  clear,  but  depositing  the  colouring  matter  of  the  blood  at  the 
bottom  of  the  vessel.  This  I have  observed  during  scarlet  fever, 
at  its  close,  and  especially  during  the  dropsical  affection  which  often 
succeeds  that  disorder. 

7.  Albumen  is  contained  in  urine  in  the  form  of  serum  or  serous 
urine.  It  is  known  by  tbe  urine  being  paler  than  usual,  by  its 
specific  gravity  being  lowered,  that  is,  being  below  1015,  generally 
about  1009,  1010,  or  1011,  and  by  being  coagulable  on  the  ap- 
plication of  heat  between  160°  and  212°  F.  The  proportion  of 

serum  varies  from  one-tenth  to  one-fifth,  in  which  case  it  forms  a 

3 


FLUIDS  OF  THE  HUMAN  BODY. 


29 


dense  firm  jelly  adhering  to  the  tube.*  The  presence  of  albumen 
always  denotes  more  or  less  disease  of  the  kidney,  particularly  the 
granular  degeneration  described  by  Dr  Bright ; and,  with  certain  ex- 
ceptions, the  greater  the  amount  of  the  coagulum,  the  more  intense 
and  decided  is  the  degree  of  degeneration.  In  scarlet  fever  it  oc- 
casionally indicates  merely  a state  of  the  kidney  allied  to  acute 
inflammation. 

8.  Purulent  matter  is  contained  in  the  urine  In  various  purulent 
or  puriform  affections  of  the  kidneys  and  bladder.  Its  presence  is 
known  by  being  observed  at  the  bottom  of  the  vessel  after  the  urine 
has  been  allowed  to  rest  for  some  time.  When  the  urine  is  first 
voided  it  is  tru-bid  and  opaque  with  numerous  Jlocculi,  and  the 
colour  is  generally  pale  straw  with  an  opalescent  tint.  After  stand- 
ing some  time  the  upper  portion  becomes  clear,  and  a layer  more 
or  less  thick  of  yellow  or  wliitish  grey  purulent  matter  is  ob- 
served at  the  bottom  of  the  tube  or  glass  jar.  The  supernatant 
urine  is  often  coagulable  by  the  application  of  heat  or  the  addition 
of  acids.  The  lower  deposit  may  be  recognised  by  the  eye  to  be 
purulent  matter  with  shreds  of  lymph ; but  it  is  more  easily  seen  by 
a good  glass  ; and  the  microscope  exhibits  distinctly  the  purulent 
globules. 

In  this  state  of  the  urine,  as  in  the  last,  the  patient  feels  frequent 
and  urgent  calls  to  empty  the  bladder,  in  which  accordingly  the 
urine  seldom  accumulates  beyond  two  or  three  ounces. 

9.  Melituria. — Sugar  is  the  most  important  foreign  or  new  substance 
which  may  be  found  in  the  urine.  The  secretion  has  in  that  state, 
when  voided,  a smell  of  whey,  or  milk,  or  new  hay,  less  agreeable, 
however,  and  somewhat  nauseous.  . Its  colour  is  generally  a pale 
honey  yellow,  but  in  some  instances  it  is  as  deep  as  that  of  porter. 
Its  density  is  always  increased,  being  generally  above  1020,  and 
rising  from  that  to  1030,  or  1035,  or  1050.  This  is  caused  by 
the  considerable  increase  of  the  solid  matters ; for  not  only  is  there 
a new  substance  in  the  sugar  contained,  but  the  urea  is  increased 
in  quantity  and  is  rarely  diminished.  It  is  supposed,  however, 
that  in  saccharine  urine  the  urea  is  diminished  as  the  disease  ad- 
vances. 

The  presence  of  saccharine  matter  in  urine  constitutes  the  patho- 
logical character  of  the  disease  named  diabetes.  With  the  increase 
in  the  amount  of  urea  and  the  presence  of  this  new  element,  the 
quantity  of  the  whole  secretion  is  greatly  increased,  so  that  within 

* Elements  of  Practice  of  Medicine,  VoL  IT.  p.  1122. 


30 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


24  hours  the  amount  of  urine  voided  is  about  six  or  seven  times 
greater  than  in  the  state  of  health. 

The  presence  of  saccharine  matter  in  the  urine  enables  it,  by  the 
addition  of  yeast,  to  undergo  fermentation  and  furnish  alcohol. 

In  this  state  of  the  urine,  saccharine  matter  is  found  also  in  the 
gastric  juice,  and  in  the  blood ; and  may  be  obtained  from  the  fluids 
by  chemical  analysis.  There  is,  tlierefore,  the  best  reason  to  be- 
lieve, that  sugar,  when  it  appears  in  the  urine,  is  previously  formed 
in  the  stomach  by  some  great  perversion  in  the  digestive  and  as- 
similative power. 


CHAPTER  III. 

FILAMENTOUS  OR  CELLULAR  TISSUE.  ( Tela  cellulosa, — Tissii  cel- 
lulaire, — Tissu  muqueux  of  Bordeu, — Corqms  Cribrosum^  Hip- 
pocratis, — Corps  Cribleux  of  F ouquet, — Reticular  membrane  of 
William  Hunter.) 

Section  I. 

The  general  distribution  of  the  filamentous  or  cellular  tissue 
was  first  maintained  by  Haller,  and  Charles  Augustus  de  Bergen, 
and  afterwards  made  the  subject  of  more  elaborate  discussion  by 
William  Hunter  and  Bordeu.  It  may  be  described  as  a substance 
consisting  of  very  minute  thready  lines,  which  follow  no  uniform 
or  invariable  direction,  but  which,  when  gently  raised  by  the  for- 
ceps, present  the  appearance  of  a confused  and  irregular  net-work. 
As  these  minute  lines  cross  each  other,  they  form  between  them 
spaces  of  a figure  not  easily  determined,  and  perhaps  not  uniform. 
By  some  authors  these  spaces  or  intervals  have  been  named  cells  ; 
but,  accurately  speaking,  the  term  is  not  fortunately  applied.  The 
component  lines,  which  do  not  exceed  the  size  of  the  silk-worm 
threads,  are  so  slender,  that  they  do  not  form  those  distinct  parti- 
tions which  the  term  cell  implies ; and  though  by  forcible  disten- 
sion, such  as  takes  place  in  insufflation  or  separation  by  forceps, 
cavities  appear  to  be  formed,  these,  it  will  be  found,  are  artificial, 
and  result  from  the  separation  of  an  infinity  of  the  slender  fila- 
ments of  which  the  part  is  composed.  These  interlineal  spaces  ne- 
cessarily communicate  on  every  side  with  each  other ; and  indeed 
the  most  distinct  way  of  forming  a true  idea  of  the  structure  of  the 
cellular  tissue  is  to  suppose  a certain  space  of  the  animal  body 


FILAMENTOUS  OR  CELLULAR  TISSUE. 


31 


which  is  divided  and  intersected  into  an  infinite  multitude  of  mi- 
nute spaces,  {areolcB^)  by  slender  thready  lines  crossing  each  other. 

This  description,  originally  derived  from  personal  observation, 
led  me  to  apply  to  this  tissue  the  name  of  filamentous  as  more  ap- 
propriate than  that  of  cellular,  by  which  it  is  generally  known.  I 
find,  however,  that  in  this  I am  anticipated  by  Charles  Augustus 
de  Bergen,  the  most  accurate  observer  who  has  treated  of  its  ana- 
tomical structure.  His  description  is  so  faithful,  that  it  should  he 
known  to  the  student  of  general  anatomy.  ‘‘  Alteram  vero  non 
adeo  distincte  saltern  paucissimis,  ut  mihi  videtur,  ohservatam.” 
He  alludes  here  to  the  filamentous  as  distinct  from  the  adipose 
tissue.  “ Ubi  sic  dicta  cellulosa  ex  innumera  atque  intricatissima 
congerie  staminum  aut  filamentorum,  nullatenus  celkdas  pingue- 
dinem  continentes  efibrmantium,  componitur ; quae  tenerrima  mi- 
rifice  oblique  disposita,  inexplicabili  adeo  contentu  viscerum  om- 
nium et  musculorum  substantiam  internam  perreptant,  ut  nihil 
certi,  vel  microcospiis  adjutus,  hie  effari  queas;  quam  proin  substan- 
tiam.  filamentosam  vocabo.”* 

The  interstitial  spaces  resulting  from  the  interlacement  of  these 
filaments  do  not  exist  as  distinct  cavities  in  the  healthy  state,  so  that 
they  cannot  be  said  to  contain  any  substance  solid  or  fluid.  But 
when  an  incision  is  made  into  this  tissue  in  the  living  body,  it  is 
found,  that,  if  we  except  those  fluids  which  issue  from  divided  ves- 
sels, nothing  is  observed  to  escape,  but  a thin  exhalation  or  vapour, 
which  is  evidently  of  an  aqueous  nature.  This  is  what  some  au- 
thors have  termed,  from  its  resemblance  to  the  serous  part  of  the 
blood,  the  cellular  serosity,  (Bichat,)  and  the  quantity  of  which  has 
been  greatly  exaggerated.  In  the  living  body  it  appears  not  to 
exist  as  a distinct  fluid,  but  merely  as  a thin  vapour,  which  com- 
municates to  the  tissue  the  moist  appearance  which  it  possesses. 

This  fluid  is  understood  to  be  derived  from  the  minute  colourless 
capillaries  named  exlialants ; and  it  is  supposed  to  he  no  sooner  pour- 
ed forth  in  an  insensible  manner,  than  it  is  removed  by  the  absorb- 
ing power  either  of  lymphatics,  according  to  the  followers  of  the 
Hunterian  hypothesis,  or  of  minute  veins,  according  to  Magendie. 
It  is  of  no  great  moment  whether  this  process  of  absorption  be  ascrib- 
ed to  lymphatics  or  to  veins,  or  be  understood,  as  is  probably  the 
truth,  to  be  effected  by  both.  It  is  sufficient  to  remark,  that,  what- 
ever serous  fluid  is  secreted  into  the  insterstitial  spaces  or  cells  of 

* CaroU  August!  a Bergen,  Progranima  de  Membrana  Cellulosa.  Francofurti  ad 
Viadrum,  de  21  Aug.  1732.  Apud  Haller,  Disputat.  Anatomic.  Select.,  VoL  III.  p. 
82. 


32 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  filamentous  tissue,  makes  no  long  abode  in  that  situation,  but 
in  the  healthy  state  is  speedily  removed  ; so  that  if  we  suppose  ex- 
halation, absorption  must  be  also  admitted ; and  the  filamentous 
tissue  is  therefore  represented  as  the  seat  of  an  incessant  exhalation 
and  absorption. 

The  serous  fluid  of  the  filamentous  tissue  varies  in  quantity  in 
different  regions.  In  the  cellular  tissue  of  those  parts  which  are 
free  from  fat,  as  in  the  eyelids,  the  prepuce,  the  nymph<B  and  lahia^ 
and  the  scrotum,  it  is  said  to  he  somewhat  more  abundant  than  in 
others.  The  peculiar  structure  of  those  parts,  which  is  cellular, 
may  render  any  excess  of  serous  fluid  more  conspicuous ; for  it  is 
matter  of  observation,  that  in  many  persons  otherwise  healthy  these 
parts  are  not  unfrequently  distended  with  serous  fluid.  On  the 
other  hand,  it  must  be  remarked  that  the  submucous  cellular  tissue, 
and  that  which  surrounds  arteries,  veins,  and  excreting  ducts,  which 
is  delicate  in  substance  and  compact  in  structure,  contains  but  a 
small  proportion  of  serous  fluid,  and  does  not  readily  admit  its 
presence. 

This  fluid  has  been  generally  said  to  be  of  an  albuminous  nature  ; 
and  if  it  be  identical  with  the  serum  of  the  blood,  from  which  it  is 
believed  to  be  secreted,  this  character  is  not  unjustly  given  it. 
Bichat,  who  maintained  this  opinion,  injected  alcohol  into  the  fila- 
mentous tissue  of  an  animal  previously  rendered  emphysematous, 
and  found  in  various  parts  whitish  Jlocculi,  which  he  regarded  as 
coagulated  albumen.  He  also  obtained  the  same  result  by  immers- 
ing a portion  of  the  scrotum  in  weak  nitric  acid ; and  when  a con- 
siderable quantity  of  this  tissue  was  boiled,  it  furnisbed  much 
whitish  foam,  which  Bichat  regarded  as  albuminous.*  These  ex- 
periments, however,  are  liable  to  this  objection,  that  the  effects  in 
question  may  have  arisen  from  coagulation  of  part  of  the  filamen- 
tous tissue  itself,  which  contains  a considerable  proportion  of  albu- 
minous matter.  The  best  mode  of  determining  the  point  is  to  ob- 
tain the  fluid  apart,  and  to  try  the  effects  of  the  usual  tests  on  it 
when  isolated  from  the  tissue  in  which  it  is  lodged. 

The  description  here  given  applies  to  the  proper  filamentous 
tissue.  This  substance  was  shown  by  Ruysch,  and  afterwards  by 
William  Hunter  and  Mascagni,  to  be  penetrated  by  arteries  and 
veins.  Exhalants,  absorbents,  and  nerves,  it  is  also  said  to  receive. 
The  arteries  certainly  belong  in  the  healthy  state  to  the  order  of 
colourless  capillaries,  which  is  nearly  the  same  with  exhalants.  It 


’ Anatomie  General,  Tome  i.  p.  50. 


FILAJiIENTOUS  OR  CELLULAR  TISSUE. 


33 


does  not  appear  that  the  nervous  twigs  observed  to  pass  through 
this  tissue  are  lost  in  it,  for  in  general  they  have  been  traced  to 
some  contiguous  part. 

Such  are  the  general  properties  of  this  tissue  considered  as  an 
elementary  organic  substance  extensively  diffused  through  the  body. 
In  particular  regions  it  undergoes  some  modifications,  which  may 
be  referred  to  the  following  heads.  1.  Beneath  the  skin,  or  rather 
under  the  adipose  membrane  ; the  subcutaneous  and  intermuscular 
cellular  tissue ; 2.  Beneath  the  villous  or  mucous  membranes ; the 
submucous  cellular  tissue ; 3.  Beneath  the  serous  membranes ; the 
subserous  cellular  tissue ; 4.  Round  blood-vessels,  excreting  ducts, 
or  other  organs ; the  enclosing  tissue,  vascular  sheaths,  &c. ; 5.  In 
the  substance  of  organs  ; the  penetrating  cellular  tissue. 

The  situation  of  the  subcutaneous  filamentous  tissue  deserves 
particular  notice.  Though  generally  represented  as  below  the 
skin,  it  is  not  immediately  under  this  membranous  covering.  The 
skin  rests  on  the  adipose  membrane,  beneath  which  again  is  placed 
the  filamentous  tissue,  extending  like  a web  over  the  muscles  and 
blood-vessels,  penetrating  between  the  fibres  and  bundles  of  the 
former,  surrounding  the  tendons  and  ligaments,  and  connected  by 
these  productions  with  a deep-seated  layer,  on  which  the  muscles 
move,  where  they  do  not  adhere  to  the  periosteum  and  to  bones. 

The  extensive  distribution  of  the  subcutaneous  filamentous  tis- 
sue, the  mutual  connection"'of  its  parts,  and  its  ready  communica- 
tion with  the  filamentous  tissue  of  the  mucous  and  serous  mem- 
branes, were  demonstrated  by  Haller,  William  Hunter,  and  Bor- 
deu,  and  have  been  clearly  explained  by  Portal  and  Bichat.  The 
principal  points  worthy  of  attention  may  be  stated  in  the  following 
manner. 

The  filamentous  tissue  of  the  head  and  face  communicate  fi’eely 
with  each  other,  and  with  that  of  the  brain  by  the  cranial  openings, 
and  with  the  submucous  tissue  of  the  eyelids,  nostrils,  lips,  and  the 
inner  surface  of  the  mouth  and  cheeks.  It  communicates  also  with 
the  subcutaneous  tissue  of  the  neck  all  round  ; and  at  the  angle  of 
the  jaw  in  the  vicinity  of  the  parotid  gland  is  the  common  point  of 
re-union.  To  this  anatomical  fact  is  referred  the  frequency  of 
swellings  and  purulent  collections  in  the  region  of  the  parotid  in 
the  course  of  various  diseases  of  the  head,  face,  and  neck. 

The  filamentous  tissue  of  the  neck  may  be  viewed  as  the  con- 
necting medium  between  that  of  the  head  and  trunk.  From  the 

c 


34 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


former  region  it  may  be  traced  downwards  along  the  back,  loins, 
breasts  sides,  flanks,  and  belly.  At  the  cervical  region,  and  be- 
tween the  shoulders,  it  is  dense  and  abundant ; and,  surrounding 
the  dorsal  part  of  the  vertebral  column  it  is  connected  with  the 
mediastinal  tissue,  the  submucous  tissue  of  the  lungs,  and  the  sub- 
serous  tissue  of  the  costal  pleura.  At  the  fore  part  of  the  neck  it 
is  in  like  manner  connected  with  the  abundant  tissue  of  the  pectoral 
region,  and  hy  means  of  that  surrounding  the  larynx  and  trachea, 
Is^,  M'ith  the  submucous  tissue  of  the  bronchi ; and,  2d,  with  the 
anterior  mediastinum.  Passing  downwards,  the  same  commu- 
nication may  be  traced  with  the  intermuscular  tissue  of  the  loins 
and  helly,  the  tissue  surrounding  the  lumbar  and  sacral  por- 
tion of  the  vertebral  column,  that  connecting  the  mesentery  and 
large  vessels  to  the  vertebrae,  and  extending  all  round  under  the 
muscular  peritonaeum,  and  into  the  pelvis,  where,  hy  means  of  the 
tissue  at  the  posterior  surface  of  the  abdominal  muscles,  at  the  an- 
terior surface  of  the  iliacus  internus^  and  through  the  obturator  hole 
and  ischiatic  notch,  it  communicates  with  the  filamentous  tissue  of 
the  lower  extremities.  From  the  rectum  and  branches  of  the  is- 
chium it  is  coniinued  along  the  perinaeum  hy  the  urethra,  and  into 
the  scrotum. 

In  the  whole  of  this  course  it  is  abundant  in  the  space  before  the 
vertebrae  round  the  psocB  and  iliacus  internus  muscles,  and  round 
the  bladder,  rectum,  prostate  gland,  and  womb.  The  tissue  sur- 
rounding the  vertebral  column  communicates  with  that  in  the  in- 
terior of  the  column  by  the  intervertebral  holes. 

The  arm-pit  may  be  considered  as  the  point  of  union  between 
the  filamentous  tissue  of  the  trunk  and  that  of  the  upper  extremi- 
ties, while  the  groin  is  the  corresponding  spot  for  the  lower  extre- 
mities. These  facts  should  be  kept  in  mind  in  observing  the  phe- 
nomena of  diseases  of  this  tissue. 

Notwithstanding  this  general  connection,  however,  certain  parts 
of  the  tissue  are  so  dense  and  close  as  to  diminish  greatly  the  fa- 
cility of  communication.  Thus  along  the  median  line  it  is  so  firm, 
that  air  injected  invariably  stops,  unless  impelled  by  a force  ade- 
quate to  tear  open  its  filaments,  and  water  is  rarely  found  etfused 
in  this  situation.  In  the  neighbourhood  of  some  parts  of  the  ske- 
leton also,  as  at  the  crest  of  the  ilium,  over  the  great  trochanter, 
and  on  the  shin,  the  filamentous  tissue  is  very  dense  and  coherent. 

In  chemical  composition  it  consists  principally  of  gelatin,  but 
contains  some  albuminous  matter. 


FILAMENTOUS  OR  CELLULAR  TISSUE. 


35 


Section  II. 

The  filamentous  tissue  is  liable  to  inflammation,  acute  and  chro- 
nic, circumscribed,  and  with  exudation  of  lymph,  or  difinsive  and 
spreading,  generally  without  this  exudation,  and  with  the  produc- 
tion of  purulent  matter  ; to  induration  ; to  hemorrhage  ; to  serous 
infiltration;  to  aerial  distension;  and  to  new  growths. 

1.  Inflammation  of  the  subcutaneous  tissue  when  circumscribed 
constitutes  phlegmon,  a name  applied  rather  in  reference  to  our 
observation  of  it  near  the  surface  of  the  body,  than  with  a view  to 
the  natural  relation  between  an  organized  texture  and  its  patholo- 
gical processes. 

In  other  situations,  as  it  is  seldom  recognized  before  it  has  pass- 
ed to  the  stage  of  suppuration,  inflammation  of  cellular  tissue  is 
generally  implied  in  those  abscesses  or  collections  of  purulent  mat- 
ter, {apostemata^  abscessus),  acute  or  chronic,  which  frequently 
form  in  the  human  body. 

Various  facts,  nevertheless,  show  that  inflammation  of  the  fila- 
• mentous  tissue  is  a process  consisting  of  several  stages.  At  first 
the  vessels  become  distended  with  blood,  which  moves  rather  slow- 
ly and  is  accompanied  with  a throbbing  or  beating  sensation.  This 
is  attended  with  more  or  less  swelling  of  the  part,  heat,  and  pain ; 
and  if  it  be  near  the  surface,  with  redness.  In  the  second  place, 
the  distended  and  overloaded  state  of  the  vessels  never  continues 
long  without  giving  rise  to  more  or  less  change  in  the  blood  in  the 
part  Serum  is  poured  out  into  the  cells,  often  sero-albuminous 
fluid ; sometimes  blood  even  is  extravasated.  The  sero-albuminous 
fluid  is  separated  into  lymph  and  serum.  The  former  gives  rise 
to  the  hardness  usually  observed.  Thirdly,  if  the  process  con- 
tinue, the  secretion  of  sero-albuminous  fluid  is  followed  by  that  of 
purulent  matter  ; and  sometimes  the  serum  first  eflFused  appears  to 
be  afterwards  converted  into  purulent  matter. 

This  purulent  matter  is  usually  contained  within  a body  of 
lymph  more  or  less  regular ; and  which  forms  a sort  of  boundary 
between  it  and  the  sound  or  uninflamed  part  of  the  tissue.  If  this 
boundary  be  complete  so  as  to  surround  and  inclose  the  purulent 
matter,  it  is  denominated  a cyst.  This  may  take  place  either  in 
acute  or  in  chronic  inflammation. 

After  the  matter  has  been  deposited  in  the  manner  now  described, 
it  evinces  a tendency  to  proceed  towards  the  nearest  surface.  This 
may  be  either  the  skin  or  any  of  the  mucous  membranes.  At  first 


36 


GENERAL  AND  rATHOLOGICAL  ANATOMY. 


it  may  be  seated  at  so  gx-eat  a dejxth  that  it  is  impossible  to  recog- 
nize its  presence.  In  a short  time,  however,  it  may  he  felt  by  the 
practised  finger.  In  most  cases,  even  where  there  is  much  hard- 
ness, it  is  generally  possible  to  predicate  the  presence  of  purulent 
matter.  The  tendency  to  advance  to  the  surface  is  connected  with 
a tendency  in  other  parts  of  the  purulent  tumour  to  contract ; and 
as  the  former  process  advances,  the  latter  keeps  pace  with  it,  so  that 
in  general,  when  the  tumour  bxxrsts  or  is  opened,  the  extent  of  the 
bottom  of  the  abscess  has  sensibly  aixd  considerably  been  dimi- 
nished. 

If  inflammation  of  cellular  tissue  do  not  terminate  in  suppura- 
tion, nor  is  resolved,  it  tei’minates  in  effusion  of  lymph,  with  con- 
cretion or  agglutination  of  its  filaments  through  a space  more  or 
less  extensive.  This  is  known  by  slight  swelling,  hardness,  and 
immobility  of  the  part.  The  phenomena  of  inflammation  in  this 
tissue  are  best  observed  in  deep  wounds,  which  divide  a conside- 
I’able  extent  of  it.  If  the  wound  be  what  is  called  simply  incised, 
the  constitution  good,  and  the  inflammation  moderate,  lymph  is 
effused,  and  the  cut  edges  are  mxited  by  what  was  anciently  named 
the  first  intention.  This  mode  of  union  was  termed  by  John  Hun- 
ter adhesive  inflammation,  (p.  226,)  and  union  by  adhesion. 

It  is  not  always,  howevei’,  that  the  process  is  so  simple.  When 
the  wound  is  extensive  or  complicated,  and  involves  the  cellular 
web  of  several  different  tissues,  the  lymph  effused  is  inadequate  to 
effect  reunion  at  once ; and  another  process  term.ed  granulation 
takes  place.  The  basis  of  this  indeed  consists  in  exudation  of 
lymph,  which  is  effused  in  minute  masses  of  no  definite  form,  and 
which  are  soon  peneti'ated  by  blood-vessels,  and  thereby  become 
organized,  (Hunter,  p.  477.)  Their  surface  becomes  covered  with 
more  or  less  lymph,  which,  as  they  increase  in  size,  causes  them 
mutually  to  cohere  ; and  by  the  successive  production,  growth  and 
union  of  these  granular  bodies,  the  divided  surfaces  are  made  even- 
tually to  unite.  The  process  of  granulation  in  the  filamentous 
tissue  is  accompanied  with  more  or  less  suppuration  ; but  as  the 
granulations  coalesce,  this  is  gradually  diminished. 

2.  The  second  form  of  inflammation  occuri’ing  in  filamentous 
tissue  is  when  it  spreads,  or  is  diffused  along  the  membi’ane,  or 
throxigh  its  substance.  John  Hunter  was  aware  of  the  tendency 
which  the  inflammatory  process  in  certain  circumstances  manifests 
to  spread ; and  referring  it  to  a sympathetic  disposition  in  the  sur- 
rounding parts,  suggests  an  illustration  in  the  opposite  qualities  of 


FILA5IENT0US  OE  CELLULAR  TISSUE. 


37 


dry  and  damp  paper.  “ If  dry,”  says  he,  “ then  it  will  not  spread ; 
it  will  be  confined  to  its  point ; but  if  damp,  it  will  spread,  being 
atti’acted  by  the  surrounding  damp  to  which  it  has  an  affinity,”  (p. 
262.)  Though  this  is  a mere  illustration,  and  is  a statement  of  a 
physical,  not  a physiological  phenomenon,  it  affords  no  imperfect 
idea  of  the  distinction  between  the  limited  or  circumscribed,  and 
the  spreading  or  diffused  inflammation. 

Two  circumstances,  however,  appear  to  have  perplexed  the  prin- 
ciples both  of  this  author  and  of  his  successors.  The  first  of  these 
was  the  sense  in  which  the  terms  erysipelas  and  erysipelatous  in- 
flammation w'ere  to  be  understood ; the  second  the  constant  search 
for  final  causes,  or  ultimate  intentions.  By  most  physicians  and 
surgeons,  previous  to  the  time  of  Carmichael  Smyth  and  Willan, 
and  even  later,  every  spreading  inflammation  was  termed  erysipe- 
latous, whether  it  existed  in  skin,  mucous  membrane,  serous  mem- 
brane, or  cellular  tissue ; and  the  character  of  nomenclature  was 
derived,  not  from  the  texture,  but  from  the  supposed  nature  of  the 
morbid  process.  This  practice,  if  not  positively  wrong,  was  at- 
tended with  confusion  in  arrangement  and  description ; and  it  is 
well  that  the  general  usage  of  correct  pathologists  has  now  re- 
stricted the  term  to  inflammation  of  a particular  tissue.  The 
second  source  of  confusion  in  the  views  of  Hunter  consisted  in  his 
regarding  the  exudation  of  lymph  as  an  invariable  barrier  against 
the  diffusion  of  the  morbid  process.  This  exudation  doubtless 
constitutes  the  character  of  the  limited  form  of  inflammation ; but 
Hunter  appears  to  have  forgotten  that,  in  certain  circumstances,  as 
in  the  sort  of  inflammation  now  considered,  this  barrier  does  not 
exist,  and  the  morbid  process  therefore  spreads,  or  is  diffused  over 
the  membrane.  It  is  further  evident  from  what  he  says,  (p.  271, 
272,  and  367,)  that  he  regarded  the  spreading  inflammation  of  the 
cellular  membrane  as  erysipelas  attacking  that  tissue,  and  that  he 
considered  its  pathological  peculiarity  to  consist  in  the  absence  of 
lymphy  effusion,  and  the  consequent  want  of  limitation.  Though 
it  may  be  disputing  about  a name  only,  to  question  this,  it  is  per- 
haps better  to  regard  this  form  of  inflammation  as  entirely  different 
from  erysipelas,  which  must  be  referred  to  the  outer  surface  of  the 
corion;  and  to  represent  it  as  a process  tending  to  spread  without 
adequate  effusion  of  coagulable  lymph. 

Another  point  in  the  pathology  of  this  disorder  may  be  here 
noticed.  Certain  facts  favour  the  notion,  thiit  it  consists  in  affec- 


38 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


tion  of  the  adipose  membrane,  as  distinct  from  the  filamentous  tis- 
saie.  Thus,  dilfuse  inflammation  occurs  mostly  in  those  parts  in 
which  the  adipose  membrane  is  abundant,  e.  g.  in  the  neck,  on  the 
chest  between  the  two  pectoral  muscles,  in  the  ann-pits,  in  the  ex- 
tremities immediately  beneath  the  skin,  and  on  the  buttock  at  the 
verge  of  the  anus.  In  the  following  passage  Hunter  seems  to  have 
this  in  view.  “ The  cellular  membrane,  free  from  the  adipose,  ap- 
pears to  be  more  susceptible  of  the  adhesive  inflammation  than  the 
adipose  membrane,  and  much  more  readily  passes  into  the  suppu- 
rative. Thus  we  see  that  the  cellular  membrane  connecting  parts 
together  as  muscles,  and  the  cellular  membrane  connecting  the 
adipose  to  muscles,  easily  inflames,  and  runs  readily  into  suppura- 
tion, and,  as  it  were,  separates  the  muscles  from  their  lateral  con- 
nections, and  even  separates  the  adipose  from  the  muscles,  while 
the  skin  and  adipose  membrane  shall  only  be  highly  inflamed,”  (p. 
234.) 

Diffuse  inflammation  of  the  filamentous  tissue  has  been  described 
by  Kirkland,  (p.  282,  Vol.  II.)  Willan,  Thomson,  and  Copland 
Hutchinson,  under  the  name  of  phlegmomid  erysipelas,  noticed  by 
various  authors  as  inflammation  of  the  fascia,  (Abernethy,  Kirk- 
land, 268,)  and  was  fully  investigated  by  Dr  Duncan  Junior  in 
1823,  under  its  proper  denomination. 

Its  general  characters  are  diffuse  swelling  spreading  over  the 
limb  or  affected  region,  compressible,  but  not  elastic,  often  doughy  ; 
deep-seated  pain,  with  an  oppressive  sensation  of  weight;  and  ten- 
sion of  the  skin,  sometimes  with  a dull  red  tinge,  not  unfrequently 
without  change  of  colour.  At  a period,  varying  from  the  fifth  to 
the  tenth  day,  the  swelling  presents  in  sundry  parts  a peculiar, 
compressible,  but  not  very  elastic  character,  as  if  the  subjacent  tis- 
sues were  floating  in  a fluid  or  semi-fluid  matter. 

If  the  affected  part  or  limb  be  examined  after  death,  the  whole 
cellular  tissue,  subcutaneous  and  intermuscular,  is  found  enlarged, 
gray,  or  ash-coloured,  and  distended  with  blood-coloured  fluid  or 
serum,  sero-purulent  or  purulent  matter.  It  is  detached  exten- 
sively from  the  several  tissues  which  it  connects  in  the  healthy- 
state.  Between  the  muscles  are  long  sinuous  caverns  filled  with 
dirty  ash-coloured  fluid ; sloughs  or  mortified  shreds  are  seen 
here  and  there  hanging  from  aponeurotic  sheaths,  tendons,  or  even 
blood-vessels ; and,  while  in  most  cases  shreds  or  filaments  of  the 
subcutaneous  or  subfascial  cellular  tissue  are  the  only  traces  of  its 


FILAMENTOUS  OE  CELLULAE  TISSUE. 


39 


existence,  in  not  a few  instances  the  muscles  are  detached  from  the 
periosteum,  and  the  periosteum  from  the  bone.  These  shreds 
are  mortified  pieces  of  sloughs  or  filamentous  tissue ; and  corre- 
spond to  the  pieces  of  wet  tow  mentioned  by  Hunter  and  Sir  E. 
Home,  and  the  wads  of  wet  chamois  leather  noticed  by  Mr  James. 

This  process  is  attended  with  much  disturbance  in  the  circula- 
tion, loss  of  appetite,  heat,  thirst,  dry  skin,  and  more  or  less  de- 
rangement of  the  intellectual  functions.  Towards  the  close  of  the 
disease,  the  pulse  becomes  quick,  small,  and  sometimes  intermit- 
ting ; the  strength  of  the  muscular  system  is  greatly  impaired  ; the 
raving  is  accompanied  with  muttering,  and  starting  of  the  tendons, 
and  alternates  with  stupor ; and  the  breathing  becomes  quick, 
panting,  and  laborious,  or  slow,  languid  and  interrupted,  and  ter- 
minates in  death. 

This  may  he  regarded  as  the  most  severe  form  of  the  disease. 
In  such  circumstances  its  duration  varies.  It  appears  from  the  re- 
sult of  Dr  Duncan’s  observations,  that  death  does  not  take  place 
before  the  sixth  day,  but  may  occur  on  any  subsequent  one  to  the 
twelfth  or  fifteenth.  Perhaps  in  the  average  number  of  cases,  the 
seventh,  eighth,  or  ninth  may  be  stated  as  the  day  on  which  the 
termination  occurs.  In  milder  cases  it  may  terminate  in  resolution 
or  in  abscess.  When  the  latter  result  takes  place,  the  inflamma- 
tory action  changes  its  character,  and  instead  of  spreading,  shows 
a tendency  to  stop.  Lymph  is  effused  ; healthy  purulent  matter  is 
formed  ; and  adhesion  taking  place  in  one  or  more  points,  the  dis- 
ease terminates  in  phlegmonic  suppuration  and  granulation. 

When  recovery  takes  place  after  suppuration  and  sloughing  of 
the  cellular  tissue,  it  is  effected  partly  by  direct  adhesion  taking 
place  between  the  muscles,  or  their  cellular  substance,  partly  by 
the  formation  of  new  cellular  tissue,  similar  to  the  new  membranes 
formed  on  the  serous  surfaces.  The  former  is  the  cause  of  the 
stiflfness,  immobility,  and  condensation  of  parts  after  this  inflamma- 
tion has  taken  place. 

In  some  instances  the  circumscribed,  or  limited,  and  the  spread- 
ing forms  of  inflammation  may  be  combined.  The  latter  proceeds 
at  one  part  of  the  affected  tissue ; while  the  limited,  with  lymphy 
exudation  and  adhesion,  takes  place  at  another.  This  appears  to 
be  the  variety  of  those  tedious  cases  in  which  the  disease  is  pro- 
longed for  weeks,  and  the  patient  either  recovers,  or  ultimately 
dies  hectic. 


40 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Diffuse  infiainmation  may  occur  in  any  part  of  the  filamentous 
tissue  of  the  whole  body,  and  may  affect  either  the  subcutaneous 
and  superficial,  or  the  intermuscular  and  deep-seated  layer.  But 
the  regions  in  which  it  is  most  commonly  observed  may  be  enu- 
merated in  the  following  order  : — 

a.  The  neck  and  throat.  (Case  by  Wells  in  Transactions  of  a 
Society,  Vol.  III.  p.  360,  and  by  Wilson,  p.  367.  Angina  inter- 
na of  Kirkland,  Vol.  II.  p.  158,  and  James,  p.  187,  &c.) 

In  persons,  generally  females,  of  full  gross  habit  and  bloated 
appearance,  swelling  diffuse,  deep-seated,  on  the  side  of  the  neck 
towards  the  angle  of  the  jaw,  causing  much  pain  in  the  side  of  the 
head ; attended  with  much  fever,  general  disorder,  loss  of  appetite, 
raving,  stupor,  or  coma.  It  terminates  in  sloughs  of  the  tissue, 
foul,  ill-conditioned  purulent  matter ; does  not  point,  but  may 
burst  internally,  and  cause  suffocation.  In  some  cases  death  takes 
place  from  the  constitutional  disorder  with  the  affection  of  the  brain. 

b.  The  breast,  or  outer  surface  of  the  chest  and  arm-pit  and  the 
side ; abscess  in  the  axilla  of  Kirkland.  Several  cases  in  Dr  Dun- 
can’s Essay.  Diffuse  painful  swelling  of  the  side  occurring  in  mid- 
dle-aged subjects,  male  or  female,  terminating  in  suppuration  all 
over  the  side,  or  between  the  pectoral  muscles,  or  in  the  arm-pit. 

c.  An  upper  extremity,  and  passing  to  the  arm-pit  and  side  of 
the  chest.  This  is  the  form  which  takes  place  after  venesection, 
after  punctured  wounds  in  dissecting,  or  the  application  of  animal 
matter  or  fluid  to  a wounded  surface. 

d.  An  inferior  extremity.  The  swelled  leg  of  puerperal  women 
is  to  be  referred  to  this  head,  (see  Hunter,  p.  204.)  Certain  in- 
juries of  the  foot  and  toes,  more  especially  when  the  fibrous  tissues 
have  been  much  lacerated,  appear  also  to  be  of  the  same  kind. 
The  phlegmonoid  erysipelas  of  the  lower  extremities  of  seamen,  as 
described  by  Mr  Copland  Hutchinson,  comes  under  this  head. 

e.  The  buttock  and  the  perinaeum.  {Proctia,  phyma  of  the  an- 
cients. Proctitis^  Proctalgia  and  Clunesia  of  the  nosologists.  Sup- 
puration gangreneuse  of  the  French.  Described  by  Pott  in  his  2d 
section  on  Fistula  ani,  p-  49.  Case  given  by  Plunter  in  his  3d 
chapter,  section  xiv.,  on  the  use  of  the  adhesive  inflammation.  Ab- 
scess anum  of  Mr  James,  p,  189.)  In  persons  of  gross  ha- 
bit, either  naturally  or  rendered  so  by  intemperance,  hard  diffuse 
swelling  of  the  verge  of  the  anus  on  each  side,  skin  doughy  and 

unresisting,  sometimes  colourless,  generally  of  a dusky  red  or  pur- 

s 


FILAJMENTOUS  OR  CELLULAR  TISSUE. 


41 


plish  colour,  -with  shivering,  sickness,  vomiting,  great  restlessness, 
heat,  and  thirst ; pulse  at  first  hard,  quick,  full  and  jarring,  after- 
wards weak,  fluttering,  and  irregular ; brown  tongue  and  mental 
disorder.  After  three,  four,  or  five  days,  a small  quantity  of  ill- 
conditioned  matter,  and  sloughs  of  the  cellular  and  adipose  mem- 
brane are  formed.  This  inflammation  may  spread  along  the  ure- 
thral and  scrotal  filamentous  tissue,  and  form  the  urethral  abscess 
(abscessus  juxta  ureihram)  of  Mr  James.  Of  this  an  instructive 
example  is  related  by  John  Hunter  at  the  passage  above  referred 
to.  The  disease  is  distinguished  according  to  him  by  the  combina- 
tion of  the  suppurative  with  the  erysipelatous  spreading  inflamma- 
tion. “ It  is  not  so  circumscribed  as  the  former ; nor  does  it 
spread  along  the  skin  like  the  latter.  But  the  skin  is  shining  and 
oedematous ; and  the  inflammation  goes  deep  into  the  filamentous 
tissue,  and  forms  dusky,  fetid,  purulent  fluid,  sometimes  with  air  in 
a bag  or  abscess,  without  previous  adhesion.”  The  inflammation 
may  pass  downward  and  forward  into  the  scrotum  and  beside  the 
urethra,  and  upwards  by  the  dense  filamentous  tissue  of  the  belly 
and  loins ; and  when  openings  are  made,  either  artificially  or  by 
the  process  of  ulceration,  matter  is  discharged,  and  the  mortified 
membrane  hangs  out  like  v/et  dirty  tow.  (Hunter,  p.  368.)  Yet, 
notwithstanding  this  extensive  destruction  both  of  filamentous  tissue 
and  even  of  skin,  it  is  remarkable  that  the  rectum  generally  escapes. 

f.  When  this  disease  appears  in  other  parts  of  the  body  after 
wounds  with  foul  instruments,  bites  of  poisonous  animals,  as  the 
rattlesnake  or  the  cobra  di  capello,  morbid  animal  secretions,  or 
the  juice  of  the  acrid  plants,  applied  in  any  manner  to  the  exposed 
corion,  its  characters  and  phenomena  may  be  easily  understood 
from  the  description  already  given. 

g.  I am  uncertain  whether  to  this  head  should  be  referred  the 
peculiar  fatal  inflammation  which  succeeds  punctured  and  lacerated 
wounds  of  the  extremities,  compound  fractures  with  much  contu- 
sion, compound  luxations  and  severe  gun-shot  wounds.  This  is 
commonly  regarded  as  gangrene,  and  is  familiarly  termed  trau- 
matic gangi-ene.  It  consists,  however,  in  a peculiar  form  of  inflam- 
mation, spreading  rapidly  along  the  subcutaneous  and  intermuscu- 
lar cellular  tissue,  accompanied  with  emphysematous  distension, 
and  causing  great  constitutional  disturbance,  in  which  disorder  of 
the  brain  and  its  functions  are  conspicuous  characters.  Death  ge- 
nerally takes  place  before  any  of  the  tissues  are  mortified,  in  con- 


42 


GENERAL  AND  PATHOLOGICAL  AJS'ATOMY. 


sequence  of  the  violence  of  the  constitutional  symptoms,  chiefly  the 
affection  of  the  brain. 

3.  Inflammation  of  a chronic  natwre  is  not  uncommon  in  the  fila- 
mentous tissue.  In  the  ordinary  acute  form,  the  process  is  attend- 
ed with  more  or  less  pain  and  swelling,  and  proceeds  quickly  to 
suppuration.  In  other  circumstances,  however,  little  or  no  pain  is 
felt;  swelling  is  not  perceived  till  late  ; and  the  first  intimation  of 
the  existence  of  the  disease  is  a collection  of  purulent  matter,  which, 
when  discharged,  is  not  homogeneous,  but  consists  of  flaky  or  cuVd- 
like  shreds  floating  in  a thinnish  watery  fluid.  This  constitutes 
the  cold  abscess  (^apostema  frigidum)  of  the  surgeons  of  the  Saracen 
school,  and  is  the  chronic  abscess  of  modern  surgeons.  (Boyer.) 

The  cold  abscess  may  be  formed  in  any  part  of  filamentous  tis- 
sue ; but  it  is  most  frequent  where  this  tissue  is  loose  and  abun- 
dant. Seldom  seen  in  the  head,  it  is  frequent  in  the  neck,  in  the 
chest,  in  the  back,  especially  in  the  lumbar  region,  and  in  the  ex- 
tremities. I have  seen  this  tumour  most  generally  in  the  loins, 
where  it  is  liable  to  be  confounded  with  lumbar  abscess ; in  the 
cellular  tissue  of  the  glutcci  muscles ; and  in  the  thigh  and  leg, 
especially  the  posterior  and  internal  region.  In  these  situations  it 
is  not  unfrequently  the  cause  of  sinuous  cavities,  which  are  difficult 
to  be  healed.  Several  of  the  forms  of  lumbar  abscess,  in  which 
there  is  no  affection  of  the  vertebrae  or  of  their  ligaments,  are  ex- 
amples of  this  abscess  occurring  in  the  abundant  loose  filamentous 
tissue,  which  connects  the  mesentery,  the  large  vessels,  and  the 
psoae  muscles  to  the  spine.  Boyer  also  states  that  they  are  some- 
times seen  in  the  filamentous  tissue  which  connects  the  serous 
membranes  of  the  chest  and  belly  to  the  walls  of  these  cavities.  Of 
the  latter  I have  seen  one  instance  simulating  hernia,  and  by  the 
destruction  which  it  caused  of  the  fibres  of  the  recti  muscles,  actu- 
ally leaving  a space  through  which  the  intestines  were  protruded. 

Ileo-c(Bcal  Abscess.  {Apostema  Ileo-ccecale.) — The  filamentous 
tissue  connecting  the  posterior  surface  of  the  caecum  to  the  lum- 
bar muscles  is  occasionally  the  seat  of  inflammation  and  suppu- 
ration, apparently  of  a chronic  character.  Swelling  and  fulness 
take  place  slowly  in  the  space  round  the  caecum.  At  length 
pain  is  felt ; and  when  the  part  is  examined  a doughy  solid 
tumour  is  reeognized  in  the  right  iliac  region,  while  dulness  on 
percussion  is  observed.  The  pulse  is  at  this  time  a little  quicker 
than  natural,  (86-90)  ; the  skin  is  dry  ; the  tongue  is  furred ; the 
abdomen  is  a little  full ; and  the  bowels  are  slow  or  obstinately 


FILAMENTOUS  OR  CELLULAR  TISSUE. 


43 


bound.  These  symptoms  increase  until  fever  is  established,  with 
more  considerable  pain  of  the  right  iliac  region  and  abdomen  in 
general,  and  the  sense  of  a hard  firm  resisting  mass  in  the  right 
iliac  region.  The  swelling  may  terminate  fatally  at  this  time  ; or 
it  may  end  in  suppuration,  either  into  the  interior  of  the  caecum,  or 
round  the  caecum,  and  into  the  iliac  fossa,  or  with  an  outlet  in  the 
region  on  the  surface  of  the  belly.  The  disease  shall  be  consider- 
ed more  fully  under  affections  of  the  caecum,  to  which  it  belongs. 

4.  Hemorrhage.  Effusion  of  blood  into  the  filamentous  tissue 
independent  of  external  violence  is  not  common.  Of  spontaneous 
and  idiopathic  hemorrhage  no  authentic  example  has  been  record- 
ed. It  occurs,  however,  in  a secondary  manner  in  land  and  sea 
scurvy,  {Purpura  and  Scorbutus),  In  the  former  disease  it  is 
rarely  to  any  great  extent,  save  when  the  complaint  has  terminated 
fatally  with  large  and  repeated  hemorrhage  from  the  mucous,  mem- 
branes. In  sea  scurvy  it  is  at  once  frequent  and  considerable. 
Scarcely  a case  of  this  disorder  attains  any  height,  without  much 
effusion  of  blood  into  the  subcutaneous  and  intermuscular  filamen- 
tous tissue.  On  this  effusion  in  general  depend  the  hard,  livid  tu- 
mours, deep  in  the  limbs,  with  which  sea  scurvy  is  attended.  The 
cause  of  this  hemorrhage,  or  rather  the  state  of  the  vessels  which 
gives  rise  to  it,  is  not  well  known.  That  the  blood  is  probably  al- 
tered, may  be  inferred  from  the  fact,  that  it  is  dark-coloured,  im- 
perfectly coagulated  and  grumous,  and  does  not  separate  into  clot 
and  serum  ; hut  the  capillaries  of  the  tissue  are  much  affected,  cer- 
tainly overloaded,  probably  disorganized. 

Similar  effusion  is  occasionally  found  in  the  filamentous  tissue  in 
malignant  agues,  remittents,  especially  those  of  tropical  countries, 
and  sometimes  in  the  fever  of  temperate  regions.  Extravasation  of 
blood,  dark-coloured  and  semi -coagulated,  are  observed  in  cases  of 
typhous  fever  during  had  epidemics,  and  in  broken  and  impaired 
constitutions.  The  patches  vary  from  the  size  of  a pea,  or  a six- 
penny piece,  to  large  irregular  shaped  masses  one  or  two  inches 
square,  and  sometimes  larger.  These  effusions  take  place  in  the 
cellular  tissue  beneath  the  skin,  in  the  intermuscular,  and  some- 
times apparently  among  the  muscles  themselves.  These  it  is  impor- 
tant to  distinguish  from  the  effects  of  blows  and  falls.  They  are 
common  in  bad  cases  of  typhous  fever.  But  it  is  possible  that  they 
may  be  aggravated  by  pressure. 

5.  Induration.  H Endurcissement  du  Tissu  Celhdaire  of  Andiy, 


44 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Auvity,  &c.  Engelure.  Scleroma  of  Chaussier,  (ax7~.rioc,jiJM  ; cxX^igos.) 
Skin-bound  of  Underwood  and  Burns.  Compact  oedema  of  M. 
Leger  and  other  French  authors.  First  observed  by  John  An- 
drew Uzembezius  in  1718,  this  affection  was  not  accurately  de- 
scribed till  1780,  when  Denman  and  Underwood  in  England,  and 
Doublet  in  France,  published  the  result  of  their  observations.  In 
1787  it  was  fully  investigated  by  Andry,  in  a memoir  crowned  by 
the  prize  of  the  Royal  Society  of  Medicine  of  Paris ; and  after- 
wards, in  1789,  in  those  of  Auvity  and  Hulme.  Since  this  it  has 
undergone  the  successive  researches  of  Naudeau  and  Bard  in 
France,  Went,  Henke,  Golis,  &c.  in  Germany,  Liherali  and  Pal- 
letta  in  Italy,  and  again  of  Trocon,  Leger,  Denis,  and  Breschet  in 
France.  Notwithstanding  the  research  of  these  several  inquirers, 
however,  the  nature  of  this  change  in  the  filamentous  tissue  is  still 
imperfectly  understood. 

It  has  hitherto  been  observed  only  in  infants,  and  very  often  im- 
mediately after  birth.  According  to  Leger,  it  appears  most  fre- 
quently eight,  twelve,  or  twenty-four  hours  after,  and  very  seldom 
takes  place  later  than  the  seventh  day.  Generally  in  the  legs,  not 
so  often  in  the  arms;  the  soft  parts  become  unusually  firm,  dense, 
and  diffusely  swelled  either  continuously  or  in  patches.  The  skin 
over  these  parts  is  hard,  rough,  and  does  not  move  easily ; and  it 
assumes  a red,  purple,  or  violet  colour,  which  when  pressed  gives 
place  to  a yellow  tint,  with  more  or  less  depression.  The  same 
change  is  very  generally  remarked  in  the  cheeks,  the  skin  of  which 
becomes  quite  immovable ; and  it  appears  successively  in  the  belly 
and  chest,  the  integuments  of  which  feel  as  stiff  as  a hoard.  At 
the  same  time  the  surface,  especially  the  extremities,  are  unusually 
cold ; the  pulse  is  quick  and  very  small ; the  breathing  is  much 
constrained  and  panting ; the  infant  ceases  to  cry,  becomes  blue  in 
the  face,  and  seems  to  expire  suffocated. 

The  duration  of  the  disease  varies.  The  greatest  number  of  in- 
fants die  on  the  first,  second,  or  third  day  from  the  date  of  attack. 
In  less  rapid  cases  death  takes  place  about  the  tenth  or  twelfth  day, 
and  in  some  so  late  as  the  twenty-first  day. 

After  death  the  surface  of  the  body  appears  in  general  hard, 
firm,  and  leathery,  and  presents  a violet  or  brownish  colour,  inter- 
spersed with  yellow  patches.  The  cheeks,  the  extremities,  and 
other  parts  affected  during  life  are  firm,  rigid,  and  immovable. 
The  subjacent  filamentous  tissue  is  very  dense  and  granular,  and 


FILAMENTOUS  OR  CELLULAR  TISSUE. 


45 


when  cut  communicates  the  sensation  as  if  it  were  like  collared 
brawn.  From  the  sections  slowly  oozes  a reddish  serous  fluid, 
which  coagulates  quickly ; and  in  the  tissue  itself  may  be  observed 
grayish  or  yellowish  granules,  which  give  the  brawny  aspect  and 
sensation  already  mentioned.  (Leger.)  The  greatest  firmness  and 
induration  are  generally  remarked  in  the  outer  region  of  the  legs, 
and  in  the  dorsal  region  of  the  foot  and  hand ; and  this  gives  the 
members  the  air  of  a peculiar  twist  or  distortion.  The  adipose 
membrane  appears  to  be  not  much  less  the  seat  of  this  disease  than 
the  filamentous  tissue. 

The  bodies  of  infants  cut  off"  by  this  disease  are  small,  being  of 
the'medium  height  of  seventeen  inches ; and  all  the  organs  are  im- 
perfectly developed.  Thus  the  lungs  are  hard,  marbled,  uncrepi- 
tating, and  sink  in  water ; the  windpipe  is  small,  and  the  alimen- 
tary canal  is  shorter  than  usual  in  healthy  infants  of  the  same  age. 
The  heart,  however,  is  large,  and  generally  contains  blood  in  clots. 
’Yas.  foramen  ovale  is  often  open,  and  the  arterial  duct  is  never 
closed.  The  pericardium,  and  frequently  the  cavities  of  the  serous 
membranes,  contain  more  or  less  serous  fluid. 

The  nature  of  this  moi’bid  change  is  unknown.  The  old  notion 
of  Uzembezius  revived  by  Andry  and  Auvity,  that  it  was  occasion- 
ed by  coagulation  of  the  fluids  frozen  by  extreme  cold,  is  com- 
pletely contradicted  by  the  fact  recorded  by  Leger,  that  among  for- 
ty-four infants  dead  during  the  month  of  June  1823  in  the  Found- 
ling Hospital  of  Paris,  twenty-one  were  cut  off  by  induration  of  the 
cellular  tissue.  The  notion  of  Alard,  that  it  is  allied  with  the 
glandular  disease  of  Barbadoes,  scarcely  deserves  mention.  On 
the  contrary,  its  early  occurrence  after  birth,  the  imperfect  deve- 
lopement  of  the  several  organs,  especially  of  the  lungs,  its  occa- 
sional appearance  previous  to  birth,  and  its  fi'equency  among  infants 
born  before  the  full  time,  (Palletta,)  show  that  it  bears  some  rela- 
tion to  the  foetal  mode  of  existence.  The  peculiar  nature  of  the  fi- 
lamentous tissue  in  the  foetus  and  in  the  new-born  infant  may  have 
some  influence  in  the  production  of  this  malady. 

6.  Serous  infiltration,  {oedema^  anasarca.)  Under  the  operation 
of  various  causes,  as  exposure  to  cold,  the  use  of  mercury,  inflamma- 
tion, or  injury,  the  quantity  of  serous  fluid  in  the  filamentous  tissue 
may  be  considerably  increased;  and  this  increase  gives  rise  to  a pale, 
white,  or  wan-coloured  and  cold  swelling  of  the  skin,  which  is  dis- 
tinguished by  receiving  the  impression  of  the  finger  or  any  other  sub- 


46 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


stance  forcibly  applied.  The  swelling  may  be  local,  or  confined  to 
one  arm,  to  one  leg,  to  a hand,  to  part  of  a limb,  to  the  scrotum,  to 
the  face,  or  so  forth ; or  it  may  extend  in  different  degrees  to  the 
greater  part  or  the  whole  of  the  person.  In  the  former  case  it  is 
termed  (Edema^  {othynMa)  or  swelling ; in  the  latter  it  receives 
the  name  of  Anasarca^  (u5gwv|/  ava  <ragx«,  dropsy  in  the  flesh,)  and 
is  the  aqua  intercus  of  the  Romans.  It  was  the  white  or  pale  and 
blanched  colour  of  this  sort  of  swelling  which  procured  for  it  the 
name  of  Leucophlegmatia  or  white  inflammation 

among  the  ancient  physicians. 

The  fluid  of  the  filamentous  tissue  may  coagulate  spontaneously, 
(Blackall,  263  ;)  but  it  always  undergoes  coagulation  on  the  appli- 
cation of  heat  or  the  addition  of  re-agents. 

The  preternatural  increase  of  the  cellular  serosity  now  mention- 
ed is  supposed  to  arise  either  from  diminished  absorption  or  in- 
creased exhalation.  This  point  will  be  considered  afterwards  when 
speaking  of  the  exhalants. 

7.  Emphysema.  Pneumatosis  spontanea  et  traumatica.,  Cullen. 
The  filamentous  tissue  may  be  distended  with  air,  which  causes 
a uniform  swelling,  crepitating  or  emitting  a crackling  sound  when 
pressed.  The  situations  in  which  this  aerial  swelling  may  take 
place  vary  according  to  the  cause  by  which  it  is  produced.  It  may 
take  place  spontaneously  (Baillie,)  when  it  is  commonly  general, 
and  is  supposed  to  depend  on  a process  of  secretion  from  the  blood- 
vessels. It  may  arise  from  rupture  or  laceration  of  the  mucous 
membrane  of  the  larynx  or  windpipe,  (De  Villars,  Cheselden, 
Holyoke,  O’Brien,)  when  the  swelling  appears  chiefly  over  the  face, 
neck,  and  upper  part  of  the  chest.  It  may  succeed  a broken  rib, 
or  any  injury  of  the  lungs,  (Littre,  Berger,  W illiam  Hunter,  Ches- 
ton,  Leake,  Gooch,  Halliday,)  when  it  appears  sometimes  over  the 
neck,  face,  and  chest,  sometimes  over  the  chest  and  side  only.  It 
may  arise  from  rupture  of  the  bronchial  membrane  during  violent 
efforts,  (Blagden,  Hicks,  Simmons;)  and  in  this  manner  emphysema 
happens  in  puerperal  women.  Lastly,  it  may  appear  as  an  effect  of 
gangrenous  inflammation  and  mortification,  when  it  is  confined  sole- 
ly to  the  affected  limb.  In  the  latter  case  the  air  is  produced  by 
the  decomposition  of  the  serum  of  the  blood  in  the  morbid  parts. 

8.  Vascular  Sarcoma,  Abernethy.  The  tumour  known  under 
this  name  is,  of  all  the  new  growths  incident  to  the  animal  tis- 
sues, the  most  simple  in  structure.  I refer  it  to  this  head  for  two 

4 


FILAMENTOUS  OR  CELLULAR  TISSUE. 


47 


reasons.  I5/,  It  appears  to  occur  chiefly  where  filamentous  or  cel- 
lular tissue  is  found  ; and  when  it  occurs  among  muscles,  or  in  the 
substance  of  organs,  it  appears  still  to  he  referable  to  the  filamentous 
tissue,  which  enters  into  the  composition  of  the  texture,  in  which 
it  appears.  2rf,  The  structure  of  this  tumour  is  principally  fila- 
mentous tissue  condensed  or  modified  by  the  local  morbid  action. 
Every  instance  of  vascular  sarcoma  may  be  viewed  as  a new  deve- 
lopement  and  hypertrophic  augmentation  of  its  proper  substance  in 
a particular  point  of  the  filamentous  tissue.  The  tumour  is  always 
liberally  supplied  with  blood  from  vessels  which,  if  not  more  nu- 
merous, are  greatly  larger  and  more  capacious  than  in  the  natural 
state ; and  if  this  be  not  the  cause  of  the  unusual  deposition  of  sub- 
stance, it  must  be  regarded  as  the  channel  by  which  the  additional 
matter  is  conveyed.  It  is  also  possible  that  the  irritation  resulting 
from  the  first  effusion  of  blood,  or  other  coagulable  matter,  which, 
according  to  Mr  Ahernethy,  is  the  usual  cause  of  tumours,  may 
excite  the  vessels  of  the  neighbouring  parts  so  much  as  to  cause 
their  capacity  to  be  enlarged,  and  to  convey  a more  copious  supply 
of  blood.  This  cause  of  the  great  vascularity,  and  its  influence  in 
increasing  the  size  of  the  tumour,  are  particularly  insisted  on  by 
Mr  John  Bell,  and  afterwards  by  Mr  Ahernethy. 

The  vascular  sarcoma  is  enclosed  in  a thin  capsule,  which  is 
formed  of  filamentous  tissue  much  condensed  by  the  pressure  of  the 
enclosed  tumour.  It  may  occur  in  any  part  or  organ  of  the  hu- 
man body  where  filamentous  tissue  penetrates ; but  it  is  also  found 
in  the  female  breast,  in  the  testicle  of  the  male,  and  in  the  absor- 
bent glands  of  both  sexes.  When  it  occurs  in  the  testicle  the  ves- 
sels are  said  to  be  numerous  and  small.  When  it  affects  the  fe- 
male breast  the  vessels  seem  to  be  rather  large  than  numerous,  and 
the  organization  appears  less  complete.  (Abernethy.) 

9.  Melanosis.  The  black  deposite  named  Melanosis  is  often 
found  in  this  tissue ; and  perhaps  when  it  is  said  to  occur  in  the 
interior  of  muscles,  glands,  and  other  tissues,  it  is  in  their  filamen- 
tous substance  that  it  is  deposited.  As  it  is,  however,  still  more 
frequent  in  the  adipose  membrane,  the  points  of  its  histoi'y  deserv- 
ing notice  shall  be  introduced  under  that  head. 

10.  Tubercle.  I am  uncertain  whether  to  this  tissue  should  be 
referred  every  variety  of  the  small  painful  bodies  situate  beneath 
the  skin,  so  well  described  by  Mr  Wood.*  Though  situate,  as  de- 

* Edinburgh  Medical  and  Surgical  Journal,  Vol.  VTII.  p.  83  and  429. 


48 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


scribed  by  Mr  Wood,  in  tbe  subcutaneous  cellular  tissue,  some 
facts  tend  to  confirm  the  notion  originally  entertained  by  Camper,* 
that  it  is  a morbid  growth  seated  in  one  of  the  subcutaneous  nerves, 
or  probably  in  its  neurilema.f 

11.  Cysts.  Bichat  has  taken  considerable  pains  to  show  the  in- 
fluence of  this  tissue  on  the  formation  of  cysts.  These,  it  is  well 
known,  are  shut  sacs  containing  fluids  of  different  sorts.  But  how- 
ever these  fluids  may  differ,  the  containing  cyst,  which  is  a secret- 
ing membrane,  has  been  regarded  as  formed  of  condensed  and  mo- 
dified filamentous  tissue.  Against  this  doctrine  Bichat  urges  the 
following  objections.  1.  Cysts  are  analogous  in  all  respects  to 
serous  membranes,  and  should  therefore  have  the  same  origin.  2. 
This  mechanical  hypothesis  of  their  origin,  in  which  all  the  vessels 
ought  to  be  obliterated,  does  not  accord  with  the  exhaling  and  ab- 
sorbing function  of  cysts,  nor  with  their  mode  of  inflammation.  3. 
If  these  sacs  are  formed  by  the  mutual  application  and  agglutina- 
tion or  adhesion  of  cells,  (that  is,  of  the  filaments,)  the  contiguous 
tissue  ought  to  be  diminished,  or  to  disappear  when  they  are  bulky, 
which  is  not  observed  to  take  place.  4.  If  cysts  are  formed  by 
condensation  of  the  filamentous  tissue,  and  if  their  fluid  is  effused 
by  exhalation,  this  fluid  ought  to  exist  in  the  organ  which  separates 
them  from  the  blood. 

For  these  reasons  he  infers  that  cysts  begin  at  first  to  be  deve- 
loped, and  to  grow  in  the  midst  of  the  filamentous  tissue,  according 
to  laws  analogous  to  those  of  the  growth  of  parts  in  general,  and 
which  appear  to  be  unknown  aberrations,  or  unnatural  applica- 
tions of  these  laws.  When  the  cyst  is  once  formed,  the  process  of 
exhalation  commences,  and  though  scanty  at  first,  it  increases  as 
the  cyst  enlarges.  In  short,  the  formation  and  growth  of  the  or- 
gan precedes  the  accumulation  of  the  fluid. 

12.  Degeneration.  This  term  is  obviously  vague  and  indefinite. 
Under  it,  however,  Sandifort  has  described  in  the  body  of  a female 
infant  a preternatural  state  of  the  cellular  tissue  of  the  breast,  back, 
and  axillary  regions.^;  In  some  respects  this  change  resembles  the 
disease  described  above  as  induration.  In  others,  however,  it  was 
different. 

* Demonstrationum  Anatomico-Pathologicarum,  Lib.  i.  p.  11. 

+ Ed.  Journal,  Vol.  XI.  p.  468. 

J Observationes  Anatomico-Pathologicse  Eduardi  Sandifort,  Lib.  iv.  cajj.  ii.  p.  24. 
Lugdimi  Batavorum,  1777.  4to 


ADIPOSE  TISSUE. 


49 


CHAPTER  IV. 

ADIPOSE  TISSUE,  ( Tela  adiposa, — Tissu  adipeux, — Tissu  graisseux.) 

Section  I, 

The  separate  existence  of  an  adipose  membrane  was  suspected 
by  Malpighi,  distinctly  taught  by  He  Bergen  and  Morgagni,  and 
demonstrated  by  William  Hunter.  It  was,  however,  confounded 
with  the  filamentous  tissue,  under  the  general  name  of  cellular 
membrane,  adipose  membrane,  and  cellular  fat,  by  Winslow,  by 
Portal,  by  Bichat,  and  most  of  the  continental  anatomists,  till  dis- 
tinguished and  positively  described  by  M.  Bedard  himself. 

According  to  the  dissections  of  De  Bergen  and  Morgagni,  the 
demonstrations  of  Hunter,  and  the  observations  of  M.  Bedard,  its 
structure  consists  of  rounded  packets  or  parcels  separated  fi-om 
each  other  by  furrows  of  various  depth,  of  a figure  irregularly  oval, 
or  rather  spheroidal,  varying  in  diameter  from  a line  to  half  an 
inch,  according  to  the  degree  of  corpulence  and  the  part  submitted 
to  examination.  Each  packet  is  composed  of  small  spheroidal  par- 
ticles, which  may  be  easily  separated  by  dissection,  and  which  are 
said  to  consist  again  of  an  assemblage  of  vesicles  still  more  minute, 
and  agglomerated  together  by  very  fine  and  delicate  cellular  tissue. 
The  appearance  of  these  ultimate  vesicles  is  minutely  described  by 
Wolff  in  the  subcutaneous  fat,  and  by  Clop  ton  Havers*  and  Monro 
in  the  marrow  of  bones,  in  which  the  two  last  authors  compared 
them  to  strings  of  minute  pearls.  If  the  fat  with  which  these  ve- 
sicles are  generally  distended  should  disappear,  as  happens  in 
dropsy,  the  vesicles  collapse,  their  cavity  is  obliterated,  and  they 
are  confounded  with  the  contiguous  cellular  tissue,  without  leaving 
any  trace  of  their  existence. 

Hunter,  however,  asserts,  that  in  such  circumstances  the  cellular 
tissue  differs  from  the  tissue  of  adipose  vesicles,  in  containing  no 
similar  cavities ; and  justly  remarks  that  the  latter  is  much  more 
fleshy  and  ligamentous  than  the  filamentous  tissue,  and  contends, 
that  though  the  adipose  receptacles  are  empty  and  collapsed,  they 
still  exist.  When  the  skin  is  dissected  fi’om  the  adipose  membrane 

* Osteologia  Nova;  or  some  New  Observations  on  the  Bones  and  the  Parts  belong- 
ing to  them.  By  Cloptcn  Havers,  M.  D.,  F.  R.  S.  London,  1691.  8vo.  P.167. 


50 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


it  is  always  possible  to  distinguish  the  latter  from  the  filamentous 
tissue,  even  if  it  contain  no  fat,  by  the  toughness  of  its  fibres,  and 
the  coarseness  of  the  web  which  they  make. 

The  distinguishing  characters  between  the  cellular  or  filamentous 
and  the  adipose  tissue  may  be  stated  in  the  following  manner. 
\st^  The  vesicles  of  the  adipose  membrane  are  closed  all  round, 
and,  unlike  the  cellular  tissue,  they  cannot  be  generally  penetrated 
by  fluids  which  are  made  to  enter  them.  If  the  temperature  of  a 
portion  of  adipose  membrane  be  raised  by  means  of  warm  water  to 
the  liquefying  point  of  the  contents,  they  will  remain  unmoved  so 
long  as  the  structure  of  the  vesicles  is  not  injured  by  the  heat.  If, 
again,  an  adipose  packet  be  exposed  to  a solar  heat  of  + 40  centigr. 
though  the  fat  be  completely  liquefied,  not  a drop  will  escape,  un- 
til the  vesicles  are  divided  or  otherwise  opened,  when  it  appears  in 
abundance.  The  adipose  matter,  therefore,  though  fluid  or  semi- 
fluid in  the  living  body,  does  not,  like  dropsical  infiltration,  obey 
the  impulse  of  gravity.  2d,  The  adipose  vesicles  do  not  form,  like 
cellular  tissue,  a continuous  whole,  but  are  simply  in  mutual  con- 
tiguity. This  arrangement  is  demonstrated  by  actual  inspection, 
but  becomes  more  conspicuous  in  the  case  of  dropsical  effusions, 
when  the  filamentous  tissue  interposed  between  the  adipose  mole- 
cules is  completely  infiltrated,  while  the  latter  are  entirely  unafiect- 
ed.  3(7.  Tile  anatomical  situation  of  the  adipose  tissue  is  different 
from  that  of  the  filamentous  tissue.  The  former  is  found,  ls7.  In  a 
considerable  layer  immediately  beneath  the  skin ; 2d,  Between  the 
peritoneal  folds  which  form  the  omentum  and  mesentery  ; 3(7,  Be- 
tween the  serous  and  muscular  tissues  of  the  heart ; and  47A,  Round 
each  kidney. 

In  each  of  these  situations  it  varies  in  quantity  and  in  physical 
properties.  In  the  least  corpulent  persons  a portion  of  fat  is  depo- 
sited in  the  adipose  membrane  of  the  cheeks,  orbits,  palms  of  the 
hand,  soles  of  the  feet,  pulp  of  the  fingers  and  toes,  flexures  of  the 
joints,  round  the  kidney,  beneath  the  cardiac  serous  membrane,  and 
between  the  layers  of  the  mesentery  and  omentum.  In  the  more 
corpulent,  and  chiefly  in  females,  it  is  found  not  merely  in  these 
situations,  but  extended  in  a layer  of  some  thickness  almost  uni- 
formly over  the  whole  person ; but  is  very  abundant  in  the  neck, 
breasts,  belly,  mons  veneris,  and  flexures  of  the  joints. 

Besides  the  delicate  cellular  tissue  by  which  the  packets  and 
vesicles  are  united,  the  adipose  tissue  receives  arterial  and  venous 


ADIPOSE  TISSUE. 


51 


branches,  the  arrangement  of  which  has  been  described  by  various 
authors  from  Malpighi,  who  gave  the  first  accurate  account,* * * §  to 
Mascagni,  to  whom  we  are  indebted  for  the  most  recent.  Accord- 
ing to  the  latter,  who  has  also  delineated  these  vessels,  the  fxirrow 
or  space  between  each  packet  contains  an  artery  and  vein,  which 
being  subdivided  penetrates  between  the  minute  grains  or  particles 
of  which  the  packet  is  composed,  and  furnishes  each  with  a small 
artery  and  vein.  The  effect  of  this  arrangement  is,  that  each  indi- 
vidual grain  or  adipose  particle  is  supported  by  its  artery  and  vein 
as  by  a foot-stalk  or  peduncle,  and  that  those  of  the  same  packet  are 
kept  together  not  only  by  contact,  but  by  the  community  of  rami- 
fications from  the  same  vessel.  These  grains  are  so  closely  attach- 
ed, that  Mascagni,  who  examined  them  with  a good  lens,  compares 
them  to  a cluster  of  fish-spawn,  {un  aggruppimento  di  uova).  Grutz- 
macher  found  much  the  same  arrangement  in  the  grains  and  vesi- 
cles of  the  marrow  of  bones,  f 

It  has  been  supposed  that  the  adipose  tissue  receives  nervous  fila- 
ments, and  Mascagni  conceives  he  has  demonstrated  its  lymphatics. 
Both  points,  however,  are  so  problematical,  that  of  neither  of  these 
tissues  is  the  distribution  known. 

The  substance  contained  in  these  vesicles  is  entirely  inorganic. 
Always  solid  in  the  dead  body,  it  has  been  represented  as  fluid 
during  life  by  Winslow,];  Haller,  § Portal,  ||  Bichat,1F  and  most  au- 

* Malpighi’s  description  is  not  much  less  accurate  than  that  of  Mascagni.  “ Vasa 
sanguinea  expandunter  in  ramos  arhorum  adinstar,  quorum  extremitatibus  appendun- 
tur  memhranosi  sacculi,  seu  lobuli,  pinguedinosis  globulis  referti,  qui  veluti  folia  ramis 
adnata  arboris  exactam  figuram  complent.” — “ Per  has  membranas  excurrunt  minima 
vasa  in  modum  retis  expansa,  quae  tenue  omentum  representant.  Haec  a venis  et  ar- 
teriis,  ut  videre  potui,  ortum  ducunt,  et  non  tantum  levitur  exterius  piguedinis  lobulos, 
Bed  etiam  intime  penetrant,  et  pinguedinosis  globulis  nectuntur.” — “ Quandoque  autem 
co-operiuntur  levi  superextensa  membrana,  ita  ut  in  conspectum  non  erumpant  ; emer- 
gunt  autem,  quotiescunque  vetustate  et  carie  membranosae  portiones  corrumpuntur.  Per 
hanc  eandem  membranam  diramificantur  adiposa  vasa  in  omento  reperta,  quse  pingue- 
dine  turgent,  si  pracipue  in  de  recenti  mactato  animali  inspiciantur.” — De  Omento, 
Pingueiline  et  Adiposis  Ductibus,  p.  41. 

-f-  De  Ossium  Medulla,  1748.  Extat  in  HaUer,  Vol.  VI.  p.  390. 

J “ La  graisse  on  matiere  graisseuse  est  plus  coulante  dans  les  vivans  que  dans  les 
morts.” — Winslow,  Traite  des  Tegumens,  sec.  73. 

§ Elementa  Physiologiae,  Lib.  i.  sect.  4. 

II  “ La  chaleur  de  la  vie  maintient  la  graisse  dans  une  espece  de  fluidite  ; eUe  se  flge 
par  le  froid  de  la  mort  ; ce  qui  fait  qu’eUe  est  compacte  dans  les  cadavres.” — Portal, 
Tome  ii.  p.  17. 

^ “ La  graisse  est  presque  toujours  solide  et  figee  dans  les  cadavres,  mais  sur  le  vi. 
vant  elle  s’approche  plus  de  I’etat  liquide,  an  moins  dans  certains  parties,  comme  aux 


52 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


thors  on  anatomy.  The  last  writer  indeed  states,  that  under  the 
skin  it  is  more  consistent,  and  that  in  various  living  animals  he 
never  found  it  so  fluid  as  is  represented.  The  truth  is,  that  in  the 
human  body,  and  in  most  mammiferous  animals  during  life,  the  fat 
is  neither  fluid  nor  semifluid.  It  is  simply  soft,  yielding,  and  com- 
pressible, with  a slight  degree  of  transparency  or  rather  translu- 
cence.  This  is  easily  established  by  observing  it  during  incisions 
through  the  adipose  membrane,  either  in  the  human  body  or  in  the 
lower  animals. 

The  properties  and  composition  of  fat  form  a subject  for  chemi- 
cal rather  than  anatomical  inquiry  ; and  in  this  respect  its  nature 
has  been  particularly  investigated  by  M.  Chevreul.  According  to 
the  researches  of  this  chemist,  fat  consists  essentially  of  two  proxi- 
mate principles,  stearine  (?sa^,  seburn^  sapo),  and  elaine,  (^eXaiov, 
oleum.)  The  former  is  a solid  substance,  colourless,  tasteless,  and 
almost  inodorous,  soluble  in  alcohol,  and  preserving  its  solidity  at 
a temperature  of  138°  centigrade.  Elaine,  on  the  contrary,  though 
colourless,  or  at  most  of  a yellow  tint,  and  lighter  than  water,  is 
fluid  at  a temperature  of  from  17°  to  18°  centigrade,  and  is  great- 
ly more  soluble  in  alcohol.  Of  this  substance  marrow  appears  to 
be  merely  a modification  ; and  the  membranous  cavities  or  medul- 
lary membrane  in  which  it  is  contained  may  be  viewed  as  an  intra- 
osseous adipose  tissue. 

Little  doubt  can  be  entertained  that  animal  fat  is  the  result  of  a 
process  of  secretion.  But  it  is  no  easy  matter  to  determine  the 
mode  in  which  this  is  effected.  Malpighi,  departing,  however, 
from  strict  observation,  imagined  a set  of  ducts  issuing  from  glands, 
in  which  he  conceived  the  fat  to  be  elaborated  and  prepared.  To 
this  he  appears  to  have  been  led  by  his  study  of  the  lymphatic 
glands,  and  inability  to  comprehend  how  the  process  of  secretion 
could  be  performed  by  arteries  only.  This  doctrine,  however,  was 
overthrown  by  the  strong  arguments  which  Ruysch  derived  from 
his  injections ; and  Malpighi  himself  afterwards  acknowledged  its 
weakness  and  renounced  it.  In  short,  neither  the  glands  nor  the 
ducts  of  the  adipose  membrane  have  ever  been  seen. 

Winslow,  though  willing  to  adopt  the  notion  of  Malpighi,  ad- 
mits, however,  that  the  particular  organ  by  which  the  fat  is  sepa- 
rated from  the  blood  was  unknown.  Haller,  on  the  contrary,  aware 

environs  du  cceur,  des  gros  vaisseaux,  &c.  Sous  la  peau  elle  est  constamment  plus 
consistante.” — Anatomie  General,  Tome  I.  p.  59. 


4 


ADIPOSE  TISSUE. 


53 


of  tiie  permeability  of  the  arteries,  and  their  direct  communication 
with  the  cells  of  the  adipose  tissue,  and  trusting  to  the  testimony 
of  Malpighi,  Ruysch,  Glisson,  and  Morgagni,  that  it  existed  in  the 
arterial  blood,  saw  no  difficulty  in  the  notion  of  secretion,  or  rather 
of  a process  of  separation ; and  upon  much  the  same  grounds  the 
opinion  is  adopted  by  Portal  and  others.  Bichat,  again,  contends, 
that  no  fat  can  be  recognized  in  the  arterial  blood,  and  adduces  the 
fact,  that  none  can  be  distinguished  in  blood  drawn  from  the  tem- 
poral artery.  It  may  be  doubted,  nevertheless,  whether  adequate 
means  to  ascertain  this  point  were  adopted.  Gmelin  obtained  from 
blood  cholesterine,  stearine,  elaine,  and  stearic  acid.  Chevreul 
obtained  from  fibrin,  by  means  of  ether,  a fatty  matter.  Lecanu 
found  in  large  quantities  of  blood  small  proportions  of  crystal- 
lizable  fatty  and  oily  matter;  and  lastly.  Dr  R.  D.  Thomson  and 
others  have  since  that  shown,  that  after  meals  of  certain  kinds 
of  food  the  blood  contains  adipose  and  oily  matter.  From  these 
facts  it  may  be  inferred,  that  adipose  matter  is  conveyed  in  mi- 
nute quantities  into  the  blood,  and  is  rapidly  deposited  from  the 
vessels  in  various  parts  of  the  adipose  tissue,  where  it  is  afterwards 
found.  From  the  phenomena  of  various  diseases  also,  and  those 
of  the  hybernating  animals,  which  retire  in  the  beginning  of  win- 
ter fat  and  heavy,  and  come  out  in  spring  meagre  and  extenu- 
ated, there  is  reason  to  believe  that  fat  is  absorbed  by  the  veins  and 
lymphatics. 

It  must  be  observed,  nevertheless,  that  fat  or  oily  matter  is  found 
in  the  free  state,  and  in  appreciable  quantity,  only  in  certain  condi- 
tions of  the  system  ; and  as  arteries  are  not  habitually  opened  for 
blood-letting,  the  circumstance  of  fat  or  oil  not  being  observed  in  cer- 
tain cases  of  arteriotomy,  forms  only  a degree  of  negative  evidence. 
This  result  is  not  at  variance  with  the  facts  observed,  as  already 
stated,  by  Hewson* * * §  and  Dr  Traill,f  who  found  oily  matter  in  ve- 
nous blood  in  two  instances,  or  with  those  observed  by  Mr  An- 
derson,! Dr  Ziegler,  Dr  Christison,§  and  myself,  all  of  whom  have 

* Hewson’s  Experimental  Inquiries,  p.  191,  loco  citato. 

+ On  the  presence  of  Oil  in  Human  Blood.  By  Thomas  Stewart  Traill,  M.  D. 
Edin.  Med.  and  Surgical  Journal,  XVII.,  236,  637,  and  XIX.  319. 

On  White  or  Milk-like  Serum.  Edin.  Med.  and  Surgical  Journal,  Vol.  XXXIII. 
p.  215. 

§ On  the  Causes  of  the  Milky  and  Whey-like  Appearance  sometimes  observed  in 
the  Blood.  By  R.  Christison,  AI.  D.  &c.  Edin.  Med.  and  Sure.  Journal,  Vol. 
XXXIII.  p.  274. 


54 


GENERAL  AND  PATEOLOGICAL  ANATOMY. 


found  tlie  blood  in  certain  morbid  states  to  contain  oil.  In  wounds 
in  the  human  body  during  life,  and  in  living  animals,  oily  par- 
ticles may  be  seen  floating  on  the  surface  of  the  blood ; but  these 
proceed  from  division  of  the  adipose  vesicles. 

That  fat  does  not  exist  in  the  arterial  blood  in  health,  or  is  in  very 
minute  quantity,  may  be  therefore  admitted  as  an  established  point. 
The  idea  that  it  is  separated,  or  strained  from  this  fluid,  therefore, 
must  also  be  gratuitous  ; and  as  such  it  is  viewed  by  Bichat,  who 
considers  the  deposition  of  fat  as  the  eflrect  of  exhalation.  This,  it 
must  be  confessed,  is  little  more  than  a different  name  for  the  pro- 
cess termed  by  Haller  secretion.  Lastly,  an  opinion  has  been  deli- 
vered by  Mascagni,  that,  while  the  arteries  deposit  or  pour  forth 
an  imperfect  or  crude  oily  fluid,  the  lymphatics  absorb  the  thin 
parts,  and  leave  the  residue  in  a more  solid  and  perfect  form. 

In  conclusion,  all  that  can  be  affirmed  regarding  the  formation 
of  this  substance  is,  that  it  is  deposited  by  the  blood-vessels,  but  by 
what  particular  process,  or  in  what  form,  is  entirely  unknown.  Tlie 
process  by  which  the  arteries  of  the  adipose  membrane  secrete  fat 
appears  to  be  equally  mysterious  as  that  by  which  the  vessels  of 
muscle  deposit  fibrine,  those  of  bone  deposit  osseous  matter,  and 
those  of  cartilage  form  that  animal  substance. 

It  appears,  therefore,  that  the  adipose  tissue  may  be  distinguish- 
ed into  two  elements,  one  organic  and  secreting ; the  other,  inor- 
ganic and  secreted. 

The  adipose  membrane  is  one  of  the  most  extensively  distributed 
tissues  in  the  animal  body;  and  this  circumstance,  with  its  peculiar 
organic  and  physiological  properties,  exercises  remarkable  influence 
on  its  inflammatory  and  other  morbid  states. 

In  distribution  it  may  be  distinguished  in  the  following  manner. 
1.  The  subcutaneous  adipose  tissue,  extended  in  a uniform  layer, 
variable  in  thickness,  beneath  the  skin  all  over  the  body,  excepting 
at  certain  parts  where  the  skin  communicates  with  the  mucous 
membrane,  as  the  eyelids,  the  lips,  the  penis  of  the  male,  the  labia 
in  the  female,  where  there  is  no  adipose  tissue,  and  beneath  the 
hairy  scalp,  where  the  adipose  tissue  is  extremely  thin  ; 2.  the  pe- 
riangial  adipose  tissue,  surrounding  and  enclosing  the  large  blood- 
vessels and  nerves  in  the  trunk  and  extremities,  forming  a sort  of 
sheath  to  these  organs,  and  sustaining  their  nutrient  vessels,  (yasa 
vasorum) ; 3.  the  subserous  adipose  tissue,  deposited,  more  or  less 
abundantly,  beneath  the  different  serous  membranes,  and  between 


ADIPOSE  TISSUE. 


55 


their  folds,  often  round  blood-vessels,  for  instance  between  the  pe- 
ricardium and  muscular  substance  of  the  heart,  betvveen  the  peri- 
toneal folds,  forming  the  omentum  and  the  mesentery ; 4.  round 
each  kidney ; 5.  between  the  folds  of  the  synovial  membranes ; 
and,  6.  the  endosteal,  or  intra-osseous,  or  the  medullary  membrane 
within  the  canals  of  the  longitudinal  bones  and  the  cells  of  the  flat 
and  short  bones. 


Section  II. 

The  pathological  relations  of  the  adipose  tissue  have  not  been 
distinctly  indicated. 

1.  Pimelitis.  Is  it  subject  to  inflammation  ? I have  already  said 
that  certain  facts  lead  to  the  inference,  that  the  peculiar  phenomena 
of  difluse  inflammation  may  depend  on  the  influence  of  the  adipose 
membrane.  This  may  be  regarded  as  established  by  many  facts. 
But  it  must  be  observed,  at  the  same  time,  that  the  physical  proper- 
ties and  the  physiological  relations  of  the  adipose  tissue,  combined 
with  its  anatomical  position,  exert  a peculiar  influence  over  its  mor- 
bid states. 

In  the  first  place,  as  the  adipose  membrane  consists  of  two  parts, 
organic  or  vital  tissue,  and  an  inorganic  secreted  substance,  and  as 
the  former  bears  a small  proportion  to  the  latter,  the  vital  proper- 
ties of  the  tissue  are  accordingly  much  less  prominent  than  the 
mere  physical  properties.  The  component  sacculi,  or  vesicles  of 
the  adipose  membrane,  are  not  possessed  of  highly  or  strongly 
marked  vital  powers ; and  the  vessels  distributed  to  them,  which 
are  neither  large  nor  numerous,  seem  to  be  merely  adequate  to 
their  nutrition  in  ordinary  circumstances,  but  quite  unable  to  main- 
tain the  energies  of  the  tissue  when  subjected  to  disease  or  injury. 
Pressure  or  stretching  the  adipose  tissue  bears  very  imperfectly ; 
and  when  it  is  subjected  to  violence  or  injury  of  this  kind  along 
with  other  tissues,  as  skin,  muscle,  cellular  membrane,  or  artery, 
its  vitality  is  destroyed  first,  and  long  before  these  tissues  are  much 
afiected.  In  continued  fever  {synochus ; typhus,)  the  adipose 
membrane  of  the  sacral  region  is  often  killed  to  a large  extent  long- 
before  the  skin  is  affected ; and  its  death  involves  necessarily  ul- 
ceration of  the  incumbent  skin,  in  order  to  allow  the  escape  of  the 
dead  adipose  membrane  in  the  form  of  a large  flat  slough.  It  is 
perhaps  of  no  great  moment  whether  this  imperfect  and  feeble  vital 


56 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


energy  depends  on  the  want  of  nerves,  or  on  the  smaller  number 
and  size  of  its  nutrient  vessels.  The  fact  of  feeble  vitality  is  well 
established  by  many  circumstances  of  daily  occurrence,  and  is  fur- 
ther illustrated,  as  shall  be  seen,  by  the  different  appearance  and 
effects  of  the  phenomena  of  inflammation  in  tissues  more  completely 
organized,  and  endowed  also  with  more  active  vital  properties. 

In  the  second  place,  as  to  anatomical  position,  the  adipose  tissue 
is  in  many  situations  of  the  human  body  so  closely  confined,  that 
when  inflamed,  and  consequently  distended,  it  cannot  easily  expand. 
This  is  particularly  the  case,  not  only  with  the  subcutaneous  fat 
which  is  compressed  by  the  skin,  but  with  the  dense  adipose  cushion 
surrounding  the  blood-vessels  and  nerves,  which,  in  the  extremi- 
ties at  least,  and  in  the  neck,  is  closely  packed  and  compressed,  as 
it  were,  by  all  the  incumbent  and  surrounding  tissues, — muscles, 
fascia,  and  skin.  When  we  examine  the  adipose  cushion  surround- 
ing the  carotid  artery  in  the  neck,  that  accompanying  the  axillary 
and  brachial  artery  in  the  arm-pit  and  arm,  and  that  enclosing  the 
femoral  and  popliteal  arteries  in  the  leg,  it  must  appear  obvious, 
that  little  or  no  space  is  left  in  either  of  these  regions  for  the  casual 
expansion  of  the  adipose  membrane,  from  whatever  cause  proceed- 
ing. Not  only  is  the  adipose  cushion  there  closely  confined  by  con- 
densed filamentous  tissue,  but  it  is  further  inclosed  and  compressed 
by  the  incumbent  fascia^  muscles,  subcutaneous  adipose  membrane, 
and  skin ; and  the  degree  of  tightness  may  be  estimated  from  the  fact, 
that  even  when  cut  into  in  the  healthy  state,  it  is  forthwith  protruded, 
and  is  with  difficulty  replaced.  This  tightness  is  one  great  cause 
of  the  readiness  and  celeraty  with  which  the  adipose  tissue  in  this 
situation  passes  so  readily  into  mortification.  As  it  is  distended  by 
the  inflammatory  vascular  congestion,  and  as  the  surrounding  parts 
do  not  yield  with  proportional  facility,  it  is  as  if  inclosed  within  a 
long  tight  ligature,  and  is  in  a manner  strangled  by  its  own  en- 
largement. This  result  is  clearly  illustrated  by  the  effects  of  in- 
flammation of  the  periangial  adipose  membrane. 

In  the  third  place,  the  inflammatory  states  of  the  adipose  mem- 
brane are  not  only  in  themselves  of  the  highest  importance,  from 
the  anatomical  and  physiological  properties  of  the  tissue  itself,  but 
in  consequence  of  the  uses  to  which  this  tissue  is  applied  in  enclos- 
ing and  supporting  others,  and  especially  the  nutrient  vessels 'of 
blood-vessels,  nerves,  tendons,  and  bones,  these  states  may  exercise 
on  the  economy  a roost  important  influence,  which  I believe  has 
not  hitherto  been  fully  understood. 


ADIPOSE  TISSUE. 


57 


Inflammation  attacking  the  subcutaneous  adipose  tissue  is  liable 
to  produce  death,  not  only  in  that  membrane  but  in  the  skin,  in- 
flammation and  death  in  the  muscles,  inflammation  in  the  subcu- 
taneous veins,  and  inflammation  and  death  in  the  tendons. 

Inflammation  attacking  the  periangial  adipose  tissue  is  liable  to 
be  followed  not  only  by  death  in  that  tissue  itself,  but  by  inflam- 
mation, death,  and  ulceration  of  the  arterial  tunics,  and  consequent 
hemorrhage,  inflammation  of  the  veins,  with  obliteration  of  their 
canal,  and  denudation  of  the  nerves. 

Inflammation  attacking  the  medullary  or  endosteal  adipose  tissue 
produces  suppuration  and  causes  death  in  the  bone,  (^Necrosis,)  and 
in  the  cancellated  tissue  the  phenomena  of  the  disease  named  Spina 
ventosa. 

When  inflammation  affects  the  adipose  membrane  it  may  assume 
either  the  limited  or  the  diffuse  form,  but  is  most  frequently  per- 
haps seen  in  the  latter  state. 

It  appears  to  have  been  an  opinion  entertained  by  Boerhaave 
and  several  of  his  pupils,  that  phlegmon,  or  common  acute  circum- 
scribed inflammation,  is  seated  in  the  adipose  membrane ; and  one 
of  these  writers,  Hulsebusch,  announces  this  proposition  formally 
in  a dissertation.  The  same  doctrine  was  afterwards  taught  in  this 
country  by  Bromfield,  who  allowed  that  the  adipose  membrane  is 
quite  distinct  from  the  filamentous  tissue,"^  and  further  believed, 
that  extravasated  fluid  would  sooner  be  converted  into  purulent 

* “ I may  be  singular  in  what  I am  going  to  advance,  viz.  that  in  general  the  adi- 
pose membrane  is  the  seat  of  abscesses,  especially  those  that  are  circumscribed. 

“ I hope  T am  understood,  that  I suppose  what  is  generally  defined  a phlegmon  or 
critical  abscess,  in  which  a large  quantity  of  matter  is  collected,  to  be  formed  in  the 
meinbrana  adiposa."  In  the  following  passage  he  gives  the  first  description  of  diffuse 
inflammation.  “ Nevertheless,  I am  extremely  sensible,  that  the  cellular  or  connect- 
ing membrane  is  frequently  the  seat  of  mischief,  as  the  receptacle  of  some  extravasat- 
ed humour,  where  the  fluids  in  general  have  a tendency  to  sphacelation  ; and  under 
such  circumstances  it  is  well  knoTO,  that  the  humour,  instead  of  being  collected  and 
forming  an  abscess,  mU  be  diffused  proportionate  to  the  quantity  extravasated,  and 
form  sloughs,  throughout  a whole  limb,  and  where  probably,  the  external  appearance 
of  sphacelation  shall  not  exceed  the  size  of  a crown-piece,  the  mortification  will  then 
discover  itself  soon  after,  at  a small  distance  ; and  we  shall  find  in  the  end,  that  it  has 
not  only  crept  under  the  skin,  but  has  bmrowed  deep  between  the  muscles,  and 
through  some  of  these  sphacelated  parts,  sloughs  of  an  immense  length  are  frequently 
drawn  out,  which  prove  to  be  the  cellular  membrane  ; in  which  case,  if  the  patient 
does  not  sink  under  the  discharge,  the  neighbouring  parts  must,  in  healing,  unavoid- 
ably unite,  and  consequently  the  hmb  be  abridged  of  its  motion,  as  far  as  the  free 
motion  of  the  muscles,  one  over  the  other,  is  hardened  by  this  union.”— Chinirgical 
Observations,  Vol.  I.  chapter  iii.  p.  94  and  95. 


58 


GENEML  AND  PATHOLOGICAL  ANATOMY. 


matter  when  lodged  in  the  adipose  than  in  the  cellular  membrane. 
It  is  further  remarkable  that,  while  he  gives  the  earliest  good  de- 
scription of  the  phenomena  and  effects  of  diffuse  or  disjunctive  in- 
flammation, he  refers  the  seat  of  circumscribed  inflammation  to  the 
adipose  membrane,  and  that  of  disjunctive  inflammation  to  the  cel- 
lular membrane.  The  converse  of  this  notion  was  maintained  by 
J.  Hunter,  who  represents  the  cellular  membrane  free  from  the 
adipose,  to  be  more  susceptible  of  the  adhesive  inflammation  than 
the  adipose  membrane,  and  much  more  readily  to  pass  into  the 
suppurative.*  This,  however,  he  afterwards  in  some  manner  con- 
troverts by  giving  the  same  view  of  the  eflPects  of  cellular  inflam- 
mation, as  that  previously  furnished  by  Bromfield. 

All  that  it  appears  to  me  can  be  concluded  at  present  on  this 
subject  is,  that,  though  inflammation  with  tendency  to  circumscrip- 
tion may  attack  the  adipose  tissue,  yet  that  tissue  is  much  more 
liable  to  assume  the  diffuse,  spreading,  and  disjunctive  form  of  the 
disease. 

Among  the  proofs  adduced  in  favour  of  this  view  may  be  men- 
tioned the  following.  In  cases  of  diffuse  inflammation  affecting  the 
arm,  the  inflammation  spreads  along  the  adipose  membrane,  pro- 
ducing sero-purulent  secretion  and  sloughs  of  the  adipose  tissue. 
In  cases  of  inflammation  at  the  verge  of  the  anus,  the  disease 
spreads  in  the  same  manner,  and  affects  almost  exclusively  the 
adipose  tissue  round  the  anus  and  rectum,  and  along  the  glutaei 
muscles.  It  is  in  the  same  manner  that  the  adipose  cushion  with 
which  the  blood-vessels  are  surrounded  is  occasionally  the  seat  of 
a species  of  bad  inflammatory  action,  terminating  in  fetid  and 
sloughing  suppuration. 

I have  in  a considerable  number  of  instances  observed  inflamma- 

* “ The  cellular  membrane,  free  from  the  adipose,  appears  to  be  more  susceptible 
of  the  adhesive  inflammation  than  the  adipose  membrane,  and  much  more  readily 
passes  into  the  suppurative.  Whether  this  arises  from  surfaces  inflaming  more  readily 
than  other  parts,  I will  not  pretend  to  say.  Thus  we  see  that  the  cellular  membrane 
connecting  parts  together  as  muscles,  and  the  cellular  membrane  connecting  the  adi- 
pose to  muscles,  easily  inflames,  and  runs  readily  into  suppuration,  and  as  it  were  se- 
parates the  muscles  from  their  lateral  connection,  and  even  separates  the  adipose  from 
the  muscles,  while  the  skin  and  adipose  membrane  shall  only  be  highly  inflamed  ; and 
the  matter  so  formed  must  produce  ulceration  through  all  this  adipose  membrane  to 
get  to  the  skin,  and  then  through  the  skin,  in  which  last-mentioned  pai-ts  it  is  much 
more  tedious.”  (P.  234,  iii.  282,  P.  ii.  Ch.  ii.  § 3.)  Himter  appears  in  this  place  to 
have  confounded  the  two  kinds  of  inflammation,  the  adhesive  or  limited,  and  diffuse 
or  suppurating. 


ADIPOSE  TISSUE. 


59 


tion  of  the  adipose  tissue,  presenting  the  external  signs  described  by 
my  late  friend.  Dr  Duncan,  Junior,  as  those  of  diffuse  inflammation 
of  the  cellular  membrane.  The  process  then  produced  all  the  ef- 
fects now  specified,  and,  by  the  peculiar  manner  in  which  the  in- 
flammatory process  spreads  along  the  meshes  of  the  tissue,  detached 
extensively  the  skin  from  the  muscles,  and  the  muscles  and  fasfdce 
from  each  other,  and,  in  consequence  of  the  intricate  manner  in 
which  it  insinuates  itself  between  the  muscles  and  their  fasciculi^ 
it  produced  extensive  disjunctive  destruction  of  the  different  parts 
which  it  affected.  Thus,  on  the  side  of  the  chest,  I have  seen  it 
first  disjoin,  and  then  kill  the  fibres  of  the  intercostal  muscles,  and, 
affecting  the  pleura  costalis  at  its  muscular  surface,  pass  to  the  ft’ee 
surface,  and  give  rise  to  pleurisy  and  empyema.  In  the  buttock, 
at  the  margin  of  the  anus,  I have  seen  it  detach  the  skin  com- 
pletely from  the  subjacent  muscles,  dissect  round  tbe  sphincter  and 
levator  ani  as  completely  as  if  done  by  the  knife,  and  produce 
such  disjunction  and  separation  as  to  render  the  whole  of  the 
muscles  completely  useless  as  organs  of  motion. 

In  the  course  of  these  destructive  processes,  this  disease,  which 
though  first  confined  with  extreme  accuracy  to  the  adipose  tissue, 
eventually  affects  muscles,  tendons,  blood-vessels,  and  nerves,  by 
killing  and.  detaching  that  texture  which  supports  and  encloses 
them,  and  conveys  their  nutrient  blood-vessels,  is  ever  attend- 
ed with  febrile  symptoms,  remarkable  for  their  character  in  de- 
ranging all  the  functions,  and  impairing  more  or  less,  sometimes 
very  considerably,  tbe  muscular  strength.  The  pulse  is  rapid,  but 
generally  much  oppressed,  and  though  sometimes  at  the  commence- 
ment sharp,  is  generally  contracted,  wiry,  and  even  vermicular. 
The  skin  is  pungently  hot  and  dry ; the  tongue  more  or  less  fur- 
red, with  much  thirst ; and  in  severe  cases,  where  the  disease  as- 
sumes a violent  character,  the  patient  raves  or  mutters,  and  some- 
times passes  into  a state  of  typhomania  (coma  vigil,)  or  even  after- 
wards coma.  The  complexion  is  often  of  a dingy  colour,  as  it  is 
in  typhous  fever,  or  in  cases  of  traumatic  gangrene,  or  in  cases  of 
death  by  animal  poisoning ; and  the  eyes,  though  they  may  be  free 
from  injection,  are  generally  suffused,  watery,  and  turbid.  At  the 
same  time,  almost  all  the  great  secretions  are  more  or  less  com- 
pletely suspended,  or  as  it  were  locked  up,  by  the  perverted  and 
diminished  action  of  the  capillary  vessels.  The  skin  is  dry  and  im- 
perspirable,  and  only  at  the  termination  of  the  disorder  betrays  the 


60 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


existence  of  clammy  moisture.  The  urine  is  scanty  and  clear  till 
the  close,  when  it  becomes  sedimentous.  No  cathartic  medicines, 
however  powerful,  can  produce  feculent  discharges  from  the  intes- 
tines, and  all  that  escapes  is  a watery  secretion  with  minute  black 
specks,  grains,  and  patches  of  undecomposed  bile,  without  the  cha- 
racteristic feculent  odour  or  aspect. 

The  peculiar  characters  of  this  form  of  fever  have  procured  for 
it,  from  Dr  Butter*  the  name  of  Irritative,  and  from  Mr  Travers, f 
that  of  Constitutional  Irritation ; denominations  which  may  be  per- 
fectly correct,  if  they  either  denoted  a new  form  of  general  disor- 
der, or  established  as  a new  principle  in  pathology,  the  circumstance, 
that  when  any  individual  texture  is  in  a morbid  state,  it  gives  rise 
to  derangement,  perversion,  and  irregularity,  in  the  motions  of  the 
sanguiferous  system  and  the  dependent  secretions.  It  appears  to 
me  that  there  is  in  this  nothing  new  nor  even  singular,  when  we 
know,  that  it  is  an  established  principle  in  physiology  and  patho- 
logy, that  all  the  textures  of  the  animal  body  are  so  allied,  that  one 
cannot  be  long  in  an  unhealthy  state  without  inducing  general  dis- 
order, and  that  all  the  properties  and  actions  of  these  textures  are 
so  intimately  associated,  that  those  of  one  organ  are  almost  never 
impaired  or  perverted,  without  betraying  the  existence  of  this  im- 
pairment or  perversion,  by  disorder  in  the  motions  and  actions  of 
the  sanguiferous  system,  and,  its  great  dependent,  the  secreting  ap- 
paratus of  the  different  organs. 

The  disease,  however,  is  not  in  all  cases  a simple  and  exclusive 
affection  of  one  tissue ; and  the  singular  feature  of  this  inflamma- 
tion is,  that,  either  simultaneously  or  successively,  it  affects  a con- 
siderable number  of  different  tissues.  It  hence  results  that  the  con- 
comitant symptoms  are  by  no  means  uniform,  and  assume  various 
types  according  to  the  tissues  affected. 

Thus,  in  inflammation  of  the  adipose  tissue,  the  disease  is  very 
liable  to  attack  the  filamentous  tissue,  which  it  disjoins  and  destroys 
in  the  manner  already  described.  It  also  very  commonly  attacks 
the  veins ; and  the  symptoms  are  then  complicated  with  those  of 
venous  inflammation ; and  may  eventually  give  rise  to  the  second- 
ary suppurations  observed  to  ensue  on  that  disoruer.  The  venous 

* Remarks  on  Irritative  Fever.  By  .John  Butter,  M.  D.,  F.  R.  S.,  &c.  Devonpoit, 

1826,  8vo.  pp.  302.  ,7  t,  c? 

•f  An  Inquiry  concerning  Constitutional  Irritation.  By  Benjamin  Travers,  F.  R.  S. 

London,  1826,  8vo,  pp.  556. 


ADIPOSE  TISSUE. 


61 


tunics  are  then  observed  to  be  thickened,  and  sometimes  adhering, 
with  obliteration  of  the  canal ; and  in  several  instances  matter,  or 
lymph,  or  both,  are  found  within  the  veins.  Lastly,  it  may  produce 
denudation  of  the  arteries  exactly  as  a broad  ligature,  or  any  fo- 
reign substance  in  the  neighbourhood  of,  or  around  the  arterial 
tubes,  and  in  this  manner  induce  erosion,  and  rupture  of  the  artery 
with  fatal  hemorrhage. 

In  ordinary  circumstances,  the  course  of  phenomena  appears  to 
be  nearly  the  following.  Sometimes  without  previous  warning,  in 
other  instances  after  slight  sensations  of  chilness  and  languor,  or 
even  after  distinct  shivering,  heavy  dull  pain  is  felt  in  one  part  par- 
ticularly, as  the  neck,  the  breast,  or  an  extremity,  according  to  the 
situation  which  the  disease  affects.  This  painful  sensation  spreads 
or  extends,  amounting  to  stiff  soreness  of  the  whole  region,  with 
more  or  less  tenderness  of  the  integuments.  If  the  part  is  exa- 
mined, it  is  found  affected  with  diffuse  or  extensive  swelling,  com- 
pressible, but  not  very  elastic,  considerable  tension  of  the  skin, 
great  heat,  and  in  some  instances  a dull  red  tinge.  In  some  in- 
stances the  skin  retains  its  natural  colour, — a circumstance  which 
is  to  be  ascribed  to  the  depth  of  the  inflammatory  action,  and  per- 
haps the  early  period  of  the  disease.  In  some  it  is  of  a faint  red, 
inclining  to  yellow  or  orange,  which  becomes  more  distinct  when 
pressure  is  applied ; and  in  some  the  disease  passes  through  every 
stage  without  even  producing  redness  of  the  skin.  In  others  long 
red  patches,  of  no  determinate  shape,  may  be  remarked ; but  this 
appearance  is  more  common  when  the  superficial  adipose  tissue  is 
affected,  and  when  the  disease  is  verging  to  suppuration.  These 
symptoms,  which  may  be  considered  as  indicating  the  first  or  in- 
flammatory stage,  last  from  thirty  hours  to  three  or  four  days, — ■ 
seventy-two,  eighty,  or  ninety-six  hours. 

As  they  proceed,  the  swelling  increases  and  may  become  more 
prominent  at  one  part  than  another,  but  still  retains  its  diffuse  and 
shapeless  character.  The  pain,  which  is  continual,  becomes  occa- 
sionally more  acute,  and  is  attended  with  an  insufferable  sensation 
of  oppressive  weight.  If  the  disease  affect  an  extremity,  the  pa- 
tient feels  as  much  difficulty  in  raising  it  as  if  it  were  a dead  mass, 
or  unconnected  with  his  person.  At  length,  about  the  fifth,  sixth, 
or  seventh  day,  according  to  the  rapidity  of  the  disease,  the  swell- 
ing presents  in  sundry  parts  a peculiar  compressible,  but  not  very 
elastic  character,  as  if  the  subjacent  tissues  were  floating  in  some 
fluid  or  semifluid  matter. 


62 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


At  this  period  the  constitutional  symptoms,  which  consist  in  quick 
sharp  pulse,  great  heat,  thirst,  loss  of  appetite,  languor,  and  some- 
times delirium,  assume  the  appearance  of  extreme  oppression  and 
mortal  weakness.  The  pulse  becomes  much  quicker,  small  and 
fluttering,  sometimes  intermittent ; the  tongue,  which  had  previ- 
ously been  covered  with  a thick,  gray,  or  yellow,  moist,  viscid  fur, 
or  was  red  and  glossy,  is  covered  with  a rough  fur,  dry,  brown,  and 
hard,  yet  the  patient  is  insensible  of  thirst.  The  skin  is  dry,  or 
partially  moistened  with  cold  unctuous  sweats ; the  urine  is  scanty 
and  high-coloured,  sometimes  entirely  suppressed,  or  passes  with 
the  stools  involuntarily ; low  mutturing  alternates  with  stupor ; 
the  breathing  becomes  quick,  panting,  and  laborious,  or  slow,  lan- 
guid, and  interrupted,  and  terminates  in  death. 

If  the  affected  part  or  limb  be  examined  after  death,  the  whole 
subcutaneous  adipose  tissue,  and  the  intermuscular  cellular  tissue, 
are  found  enlarged,  gray,  or  ash-coloured,  and  distended  with 
blood-coloured  fluid,  oily  serum,  or  sero-purulent,  or  purulent 
matter.  It  is  detached,  in  general,  extensively  from  the  several 
organs  which  it  connects  in  the  healthy  state.  Between  the  mus- 
cles, which  are  dark-coloured,  softened,  lacerable,  and  emit  a fetid 
odour,  are  found  long  sinuous  caverns  filled  with  dirty  ash-co- 
loured purulent  fluid ; sloughs  or  mortified  shreds  are  seen  here 
and  there  hanging  from  aponeurotic  sheaths,  tendons,  or  even 
blood-vessels ; and  while  in  most  cases  shreds  or  filaments  of  the 
subcutaneous  adipose  and  the  cellular  tissue  are  the  only  traces  of 
its  existence,  in  not  a few  instances  the  muscles  are  detached  from 
the  periosteum,  and  the  periosteum  from  the  bone.  These  shreds 
or  filaments  are  mortified  pieces  or  sloughs  of  adipose  membrane 
and  cellular  tissue,  and  correspond  to  the  pieces  of  wet  tow  men- 
tioned by  Hunter  and  Sir  E.  Home,  and  the  wads  of  wet  shamoy 
leather  noticed  by  Mr  James. 

This  may  be  regarded  as  the  most  exquisite  and  severe  form  of 
the  disease.  Its  duration  in  such  circumstances  varies.  It  appears 
from  the  result  of  Dr  Duncan’s  observations,  that  death  does  not 
take  place  before  the  sixth  day,  but  may  occur  in  any  subsequent 
one  to  the  twelfth  or  fifteenth.  Perhaps  in  the  average  number  of 
cases,  the  seventh,  eighth,  or  ninth  may  be  stated  as  the  day  on 
which  the  termination  occurs. 

In  milder  cases  it  may  terminate  in  resolution.  The  general 

swelling  subsides  slowly,  the  pain  disappears,  the  skin  becomes 

] 


ADIPOSE  TISSUE. 


63 


cool ; and  the  constitutional  symptoms  decline  upon  the  eruption 
of  a copious  sweat,  a cutaneous  disease  or  other  critical  action. 

It  may  terminate  in  abscess.  The  inflammatory  action  changes 
its  character,  and,  instead  of  spreading,  shows  a disposition  to  stop. 
Lymph  is  effused,  healthy  purulent  matter  is  formed,  and  adhesion 
taking  place  in  one  or  more  points,  the  disease  terminates  in  phleg- 
monic suppuration. 

In  some  instances  the  spreading  and  limited  may  be  combined. 
The  spreading  or  diffuse  inflammation  proceeds  at  one  part  of  the 
affected  tissue,  while  the  limited  with  lymphy  effusion  and  adhesion 
appears  at  another.  This  appears  to  be  the  fact  in  those  tedious 
cases  in  which  the  disease  is  prolonged  for  weeks,  and  the  patient 
either  recovers,  or  ultimately  dies  hectic. 

When  recovery  takes  place  after  suppuration  and  sloughing  of 
the  adipose  and  cellular  tissue,  it  is  effected  partly  by  direct  adhe- 
sion taking  place  between  the  muscles  or  their  cellular  substance, 
and  the  skin,  partly  by  the  formation  of  new  cellular  tissue  similar 
to  those  new  membranes  which  are  formed  in  the  serous  surfaces. 
The  former  is  the  cause  of  the  stiffness,  immobility,  and  condensa- 
tion of  parts  after  this  inflammation  has  taken  place. 

The  causes  of  this  disease  are  not  well  known.  There  is  reason 
to  believe  that  it  requires  for  its  production  a peculiar  state  of  the 
constitution  ; for  it  more  readily  attacks  the  bloated  and  those  of 
broken  constitutions  than  the  spare  and  the  vigorous ; it  is  more 
common  and  more  severe  in  the  corpulent  and  plethoric  than  in 
those  of  healthy  and  active  habits;  it  is  more  common  in  those 
liable  to  mental  inquietude  and  peevishness  than  to  those  of  equable 
or  indifferent  temperament ; and  the  same  exciting  cause  which 
produces  in  a young  and  healthy  subject  a common  phlegmonic 
abscess,  will  be  follov/ed  in  a sallow  or  middle-aged  person,  of  dry 
or  unctuous  skin,  with  a fatal  inflammation  of  the  dift’use  character. 
Something  also  appears  to  be  attributable  to  epidemic  influence ; 
for  several  cases  are  generally  remarked  to  occur  much  about  the 
same  time ; and  it  has  been  further  remarked,  that  when  rose, 
scarlet  fever,  and  bad  sore  throat  prevail,  instances  of  diffuse  inflam- 
mation are  not  unfrequent. 

With  regard  to  agents  wliich  appear  to  possess  exciting  power, 
it  may  occur  spontaneously  : but  has  been  observed  to  succeed  the 
following  circumstances ; venesection  and  punctured  wounds  in 
general,  application  of  a ligature  to  a vein,  puncture  by  a cutting 


€4 


GENERAL  AND  PATHOLOGICAL  ANATOOT. 


instrument  during  dissection,  inoculation  by  morbid  secretions 
from  living  animals,  the  bite  of  a venomous  serpent,  acrid  or  poi- 
sonous substances  of  the  acrid  family  applied  directly  to  the  skin 
or  adipose  membrane,  sprains  or  injuries  of  the  fibrous  tissues,  and 
contused  or  lacerated  wounds. 

Though  this  disease  may  arise  both  spontaneously,  and  also  in 
consequence  of  lacerated  or  punctured  wounds,  or  even  mere 
scratches  or  abrasions,  and  in  consequence  of  various  poisonous 
substances  applied  to  the  skin  or  the  adipose  membrane,  it  appears 
further,  in  certain  circumstances,  to  ensue  on  the  application  to 
the  skin  of  various  acrid  and  irritant  poisons.  Thus,  in  the  expe- 
riments of  Orfila  upon  the  mode  of  operation  of  these  poisons,  it 
was  a frequent  occurrence,  to  observe  diffuse  inflammation  in  the 
adipose  tissue  ensue  on  the  application  of  such  substances  as  bry- 
ony-root, elaterium,  colocynth,  gamboge,  spurge-flax,  euphorbium, 
&c.  to  the  skin  or  the  adipose  membrane  exposed  by  wound.  Dr 
Duncan  relates  a case  communicated  by  Dr  Spens,  in  which  it 
followed  the  application  of  an  ammoniacal  plaster  for  the  removal 
of  rheumatic  pains.  It  has  been  observed  to  follow  or  attend  ma- 
lignant pustule.  (Practice  of  Medicine,  Vol.  i.  p.  656.) 

The  account  of  the  necroscopic  appearances,  however,  above 
given,  is  applicable  principally  to  the  disease  as  it  takes  place  in 
the  subcutaneous  adipose  tissue ; and  perhaps,  as  it  spreads  to  the 
intermuscular  filamentous  tissue.  These  appearances,  though  in 
all  general  characters  similar  in  other  tissues,  are  varied  according 
to  the  portion  of  adipose  membrane  attacked. 

The  disease  may  either,  when  originally  commencing  in  the  sub- 
cutaneous adipose  tissue,  spread  to  the  periangial,  or  it  may  com- 
mence in  the  latter  at  once,  and  produce  destructive  ravages  in  the 
periangial  sheath,  and  most  pernicious  effects  on  the  blood-vessels. 
Thus,  I have  elsewhere  recorded  the  principal  circumstances  of  a 
case  in  which  the  disease  attacked  the  periangial  adipose  tissue  of 
the  right  carotid  artery  and  jugular  vein,  destroyed  the  sheath  for 
the  space  of  eight  inches,  denuded  and  exposed  both  vessels,  pro- 
duced gangrene  and  erosion  of  the  artery  and  inflammation  of  the 
jugular  vein,  with  obliteration  of  its  canal,  and  denudation  of  the 
trunk  of  the  pneumogastric  nerve.  (Edin.  Med.  and  Surgical 
Journal,  Vol.  xlviii.  p.  396.) 

The  adipose  tissue  connected  with  the  internal  organs  is  also 
liable  to  be  attacked  by  inflammation.  That  enclosing  the  kidneys 


ADIPOSE  TISSUE. 


65 


in  particular  has  been  found  affected  with,  and  destroyed  by,  the 
true  disjunctive  inflammation.  One  of  the  most  characteristic  ex- 
amples of  this  disease  on  record  is  given  by  Dr  Thomas  Turner, 
in  the  fourth  volume  of  the  Medical  Transactions  of  the  Royal 
College  of  Physicians.  In  this  case  the  disease  commenced  with 
sickness,  vomiting,  and  pain  in  the  bowels,  followed  by  pain  in  the 
back  and  loins ; and  at  the  end  of  about  thirty-eight  hours  with 
great  restlessness,  anxiety,  laborious,  panting  respiration,  and  loss 
of  pulse  at  the  wrist.  Death  took  place  at  the  end  of  forty-eight 
hours.  The  whole  adipose  tissue  enclosing  the  kidneys  was  in  a 
gangrenous  state,  exhibiting  a large  mass  of  black  pulpy  matter. 
The  capsules  of  both  kidneys  were  inflamed,  that  of  the  right  kid- 
ney mortified,  and  slight  traces  of  inflammation  were  observed  in 
the  internal  structure  of  both  kidneys.  In  the  winter  of  1816-17, 
I examined  the  body  of  a man  in  whom  I found  the  whole  of  the 
adipose  cushion  surrounding  the  left  kidney,  converted  into  an  ash- 
coloured  fetid,  semifluid  pulp,  similar  to  a mixture  of  train  oil  and 
jelly,  mingled  with  shreddy  filaments,  and  in  which  this  suppura- 
tive sloughing  process  had  opened  a passage  from  the  fat  of  the 
left  kidney  into  the  interior  of  the  transverse  arch  of  the  colon.  In 
this  case,  though  the  patient  did  not  complain  of  much  pain,  and 
presented  chiefly  the  general  languor,  oppression,  and  stupor  ob- 
served in  typhoid  fever,  the  pulse  was  quick  and  small,  the  tongue 
brown  and  dry,  the  thirst  intense,  afterwards  not  felt,  the  counte- 
nance dingy  and  lurid,  and  the  eyes  heavy,  the  bowels  difficult  to 
be  affected  by  medicine,  the  urine  scanty  and  high-coloured,  and 
at  length  suppressed  ; and  the  patient,  after  muttering  delirium  and 
typhomania  on  the  second  day  of  the  attack,  with  subsultus  tendinum, 
passed  into  a comatose  state,  which  terminated  on  the  fourth  day 
in  death. 

The  endosteal  or  intra-osseous  adipose  tissue,  in  other  words,  the 
medullary  membrane,  is  liable  in  like  manner  to  both  forms  of  in- 
flammation, but  especially  the  suppurative  and  disjunctive ; and 
the  invariable  eflrect  of  this  is  to  kill  the  compact  tissue  of  the  bone, 
and  produce  atomical  death  or  caries  of  the  cancellated  tissue.  Ne- 
crosis is  the  result  of  the  former,  and  spina  ventosa  and  caries  of 
the  latter.  The  full  consideration  of  this  variety  of  the  disease, 
however,  belongs  to  another  subject. 

I have  now  described  the  usual  characters  of  this  disease  in  its 

E 


66 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


most  acute,  intense,  and  rapid  form.  But  it  sometimes  happens 
that  it  is  slower  in  progress  and  less  intense  in  severity  ; and  in 
this  case  it  may  be  said  to  be  subacute  or  chronic.  Thus  I have 
seen  an  instance  in  which  the  disease  attacked  the  adipose  tissue  of 
the  arm,  and  though  attended  with  well-marked  fever,  yet  without 
the  overpowering  symptoms  of  prostration  so  often  observed, — 
and  advancing  so  slowly  as  to  admit  of  the  employment  of  local 
depletion  by  leeches,  and  the  effect  of  antimonials  and  purgatives, 
so  as  eventually  to  terminate  in  resolution. 

The  foregoing  account  may  communicate  some  idea  of  the  seat 
of  this  disease,  of  its  effects,  and  of  its  dangerous  tendency.  I have 
yet  to  offer  a few  remarks  on  its  nature,  its  pathological  peculiari- 
ties, and  the  causes  on  which  its  developement  may  seem  to  depend. 
Some  of  these  points  I have  indeed  anticipated.  But  others  are 
entitled  to  more  systematic  examination. 

The  most  remarkable  circumstance  in  tbe  pathological  history  of 
Pimelitis,  is  the  extreme  rapidity  with  which  it  generally  proceeds 
to  sero-purulent  infiltration  and  disjunctive  destruction.  In  several 
cases  this  has  been  known  to  take  place  within  thirty -six  hours 
from  the  appearance  of  the  first  symptoms  of  uneasiness.  In 
others  it  occurs  in  the  course  of  about  seventy-two  hours;  and 
in  very  few  cases  is  this  event  protracted  beyond  the  fourth 
day. 

Very  nearly  at  the  same  rate  may  be  estimated  the  fatality  of 
the  disease.  Wherever  the  inflammation  is  very  extensive,  and  es- 
pecially if  it  occur  in  middle-aged  or  elderly  corpulent  persons, 
death  is  very  likely  to  ensue  in  the  course  of  the  third,  or  at  most, 
the  fourth  day.  In  young  and  robust  persons,  on  the  contrary, 
and  in  whom  the  adipose  tissue  is  not  much  loaded,  the  disease  is 
slower  in  progress,  and  less  frequently  fatal  in  termination.  The 
most  rapidly  fatal  case  which  I think  I have  yet  witnessed  occurred 
in  a male  patient  in  the  Boyal  Infirmary  this  season.  He  had  been 
under  treatment  for  slight  diarrhoea,  which  disappeared  under  the 
use  of  chalk  mixture  and  opiates,  alternated  with  gentle  eccopro- 
tics,  and  the  use  of  nutritious  diet,  and  for  several  days  expressed 
himself  well.  He  was  in  his  usual  health  at  the  visit  preceding  the 
last  day  of  his  life ; but  in  the  afternoon,  about  four,  he  was  at- 
tacked with  pain  of  the  left  thigh  and  iliac  region,  which  speedily 
became  swelled,  hot,  red,  and  livid,  and  presented  a large  detach- 
ment of  the  cuticle,  containing  livid  serum  {phhjctana.y^.^Q's.t 


ADIPOSE  TISSUE. 


67 


day  the  features  were  decomposed,  the  face  pale,  the  counte- 
nance Hippocratic;  and  death  took  place  the  same  evening,  with- 
in twenty-six  hours  from  the  first  appearance  of  symptoms.  Upon 
inspection,  the  whole  adipose  membrane  was  found  extensively 
infiltrated  with  dirty  oily-like  serum.  The  arteries  were  not  dis- 
eased. 

Anatomico-Pathological  Causes  of  Disjunctive  Inflam- 
mation.— Though  I do  not  deny  that  this  disease  is  occasionally 
to  be  seen  in  the  filamentous  tissue,  yet  I think  this  is  a much 
rarer  occurrence  than  in  the  adipose  membrane  ; and  several  cir- 
cumstances appear  to  prove,  that  it  is,  if  not  the  only,  at  least  by 
far  the  most  common,  form  of  inflammation  in  that  tissue.  This 
conclusion  is  founded  not  only  on  the  anatomical  fact  of  the  adipose 
membrane  being  found  most  usually  the  seat  of  the  disease,  and  of 
its  affecting  parts  where  this  texture  is  most  abundant,  as  already 
-stated,  but  also  in  another  circumstance,  viz.  that  the  disease  is 
most  frequent  in  corpulent  persons,  in  whom  the  adipose  tissue  is 
abundant.  This  circumstance  again  seems  to  be  referable  to  the 
low  vital  energy  of  that  tissue,  as  already  in  some  degree  ex- 
plained. 

In  the  corpulent,  either  by  habit  or  age,  in  whom  this  disease 
assumes  its  most  exquisite,  intense,  and  unmanageable  forms, — 
who  are  generally  not  only  plethoric,  but  bloated,  and  liable  to  im- 
perfect circulation,  and  disorders  of  tbe  circulation  and  secretion 
generally, — and  in  whom  slight  causes  are  often  followed  by  serious 
disorders,  the  adipose  tissue  appears  to  lose  a great  proportion  of 
the  small  degree  of  vital  energy  which  it  possesses,  and  the  more 
abundant  the  secreted  product  is,  the  less  active  are  its  vessels 
and  the  inherent  properties  of  the  membrane.  In  consequence  of  this 
greatly  impaired  energy,  slight  causes,  as  cold,  scratches,  or  abrasions, 
punctures,  contusions,  &c.  are  suddenly  followed  by  a more  or  less 
complete  loss  of  circulation  and  action  in  tbe  tissue ; for  the  disease 
consists  not  in  increased,  but  diminished  action ; and  this  impaired 
energy  continues,  until  the  natural  functions  of  the  tissue  become 
extinct.  In  these  circumstances,  with  few  and  inert  blood-vessels, 
the  secreted  or  inorganic  matter  of  the  adipose  tissue  becomes,  as 
it  were,  a cause  of  strangulation  of  tbe  tissue  itself,  or  at  least  tends 
so  directly  to  suppress  the  energies  of  its  organic  part,  that  it  is 
incapable  of  resisting  the  influence  of  morbific  agents  of  ordinary 
power ; and  hence,  the  organic  portion  either  may  be  smitten  with 


68 


GENERAL  ANB  rATHOLOGICAL  ANATOMY. 


immediate  death,  or  is  easily  made  to  assume  a very  low,  languid, 
and  imperfect  form  of  morbid  action,  which  speedily  terminates  in 
death. 

This  low  degree  of  vital  energy  seems  the  principal  if  not  the 
sole  cause  of  the  disjunctive,  and,  as  it  may  be  termed,  the  disor- 
ganizing character  of  the  inflammation,  of  which  the  adipose  mem- 
brane becomes  the  seat.  If  we  compare  the  different  elementary 
tissues  of  the  animal  body,  we  find  that  the  nature  of  the  inffamma- 
tory  process,  of  which  each  becomes  the  seat,  bears  a relation  more 
or  less  intimate  and  direct  to  the  nature  of  its  organization.  All 
parts  well  provided  with  blood-vessels,  and,  therefore,  highly  orga- 
nized, seem  to  have  high  vital  energies,  and  great  powers  of  resist- 
ing disorganization.  Parts,  on  the  other  hand,  less  highly  orga- 
nized, and  which  have  few  or  small- sized  blood-vessels,  may  be 
said  to  have  inferior  degrees  of  organization,  and  to  be  less  capable 
of  resisting  the  vascular  perversion  in  which  inflammation  consists. 
Thus  the  skin,  the  serous  membranes,  and  the  mucous  membranes, 
all  of  which  are  highly  vascular,  possess  also  great  powers  of  resist- 
ing the  disorganizing  effects  of  inflammation  ; and,  when  these  take 
place,  either  counteract  this  by  some  supplementary  process,  which 
inflicts  no  serious  injury  on  the  structure  of  the  inflamed  membrane, 
and  does  not  permanently  injure  its  functions,  or,  if  actual  destruc- 
tion ensue,  it  is  not  by  direct  death  of  the  part,  but  by  the  minute 
atomical  absorption  named  ulceration  ; and  at  the  same  time  the 
vessels  make  attempts,  though  sometimes  abortive,  to  repair  this 
species  of  destruction. 

My  limits  do  not  allow  me  to  consider  at  length  the  apparent 
exceptions  to  this  principle,  otherwise  it  would  appear  distinctly 
that  these  were  only  confirmations  of  the  fact  now  stated, — that 
the  protecting  faculty  of  any  tissue  against  the  ravages  of  inflam- 
mation depends  very  much  upon,  if  it  be  not  directly  proportioned 
to,  its  organization,  or  the  size  and  number  of  its  nutrient  vessels. 
This  principle  is  also  very  clearly  illustrated  in  the  inflammation  of 
the  adipose  membrane,  in  which  an  imperfect,  and,  indeed,  an  in- 
ferior degree  of  organization  seems  to  be  the  main  cause  of  the 
destructive  effects  of  that  process.  In  that  tissue  inflammation  is 
no  sooner  established  than  it  proceeds  rapidly  to  death,  chiefly  be- 
cause the  texture  has  not  powerful  vital  energies,  and  is  less  capa- 
ble than  others  of  resisting  the  tendency  to  destruction.  It  pos- 
sesses less  of  the  independent  form  of  vitality  which  the  vascular 


ADIPOSE  TISSUE. 


system  communicates  to  all  the  elementary  tissues  of  the  frame, 
and  hence  sinks  more  easily  and  promptly  under  the  influence  of 
the  perverted  or  impaired  vascular  disorder  in  which  inflammation 
consists. 

It  is  not  unlikely  that  this  is  also  one  of  the  principal  causes  of 
the  peculiar  irritative  characters  of  the  febrile  disorder  with  which 
the  inflammation  of  the  adipose  tissue  is  attended.  We  know  that 
in  the  case  of  inflammation  of  highly  organized  tissues,  as  the  se- 
rous membranes,  the  character  of  the  concomitant  fever  is  often 
distinct  and  acutely  inflammatory, — much  perverted  action  of  the 
vascular  system,  but  little  of  the  nervous  system,  and  much  less  of 
the  overpowering  prostration  and  oppression  of  all  the  vital  powers 
which  attend  inflammation  of  the  adipose  membrane.  In  the  one 
case,  the  actions  of  life  seem  to  be  simply  increased,  and  are  cer- 
tainly perverted,  and  in  one  respect  augmented  in  intensity.  In 
the  other,  they  are  oppressed  and  overpowered ; and  the  full  vi- 
gom’  of  reaction,  as  it  has  been  named  in  the  mechanical  lan- 
guage of  the  iatro-matheraatical  schools,  is  not  permitted  to  deve- 
lope  itself. 

But  it  is  not  only  in  its  constitutional  effects  that  inflammation 
of  the  adipose  tissue  is  a malady  so  important.  From  its  intimate 
union  with  the  parts  which  it  incloses,  its  destruction  entails  their 
destruction  ; and,  if  it  do  not  prove  fatal  by  the  severity  of  the  fe- 
brile disorder  which  it  induces,  it  may  do  so  by  the  ravages  which 
it  causes  among  muscles,  nerves,  and  blood-vessels.  I mentioned 
its  tendency  to  expose  and  denude  the  blood-vessels ; because  in 
almost  all  the  dissections  which  I have  seen  and  performed  of  this 
disease,  I have  found  the  vascular  sheath  more  or  less  diseased, 
sometimes  destroyed,  and  the  vessels  exposed,  the  veins  thickened 
and  inflamed,  and  the  arteries  brittle,  softened,  and  sloughy.  In 
all  these  cases,  however,  the  disease  proves  fatal,  either  by  the  in- 
tensity of  the  febrile  disorder,  or  by  causing  inflammation  of  the 
veins,  or  passing  to  some  internal  organ,  as  for  instance  when  it 
affects  the  adipose  membrane  of  the  chest,  and  thence  passes,  as  I 
have  seen  it,  to  the  pleura  and  lungs.  It  cannot  be  doubted,  how- 
ever, that,  were  life  not  terminated  in  either  of  these  modes  now 
mentioned,  the  destruction  of  the  adipose  tissue,  forming  the  sheath 
of  the  vessels,  would  have  the  effect  of  producing  death  in  the  ar- 
terial tunics,  and  rupture  of  these  vessels.  We  know,  that  when 
the  sheath  is  by  any  means  detached  from  the  arterial  tunics,  either 


70 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


by  disease,  oi’  aceident,  or  in  consequence  of  operation,  a result  al- 
most inevitable  is  death  of  these  tunics,  chiefly  in  consequence  of 
the  destruction,  which  the  nutrient  vessels,  the  vasa  vasorum^  ne- 
cessarily sustain  by  the  inflammation  of  the  adipose  sheath,  by  which 
these  vessels  are  supported.  That  this  has  not  been  more  frequently 
observed  in  cases  of  spontaneous  inflammation  of  the  adipose 
cushion,  is  to  be  ascribed  to  the  fact,  that  the  disease  in  general 
proves  fatal  by  the  severity  of  the  constitutional  disorder,  or  by  the 
induction  of  inflammation  of  the  veins,  passing  from  their  exter- 
nal to  their  internal  coat. 

It  is  proper  to  remark,  that  in  an  abstract  of  the  case  of  inflam- 
mation of  the  periangial  adipose  tissue  above  referred  to,  in  the 
Archives  Generales,  (iii.  New  Series,  Dec.  1837,)  M.  Godin,  the 
author  of  that  notice,  has  attempted  to  oppose  the  view  that  the 
disease  consists  in  inflammation  of  the  adipose  membrane,  by  re- 
presenting it  to  be  diffuse  phlegmon.  I have  only  to  remark,  that 
this  is  a contradiction  in  terms,  which,  instead  of  conveying  a cor- 
rect view  of  the  disease,  tends  to  confuse  still  more  than  formerly. 
The  view  given  by  me  rests  on  the  accuracy  of  the  anatomical 
observations ; and  unless  these  are  shown  to  be  erroneous,  1 see 
no  mode  of  denying  the  fact,  that  in  most  of  the  cases  of  diffuse 
inflammation  the  adipose  membrane  is  the  chief  seat  of  the  dis- 
ease. 

2.  Hemorrhage.  EflPusion  of  blood  into  the  adipose  tissue  is 
not  very  common.  It  is  observed  in  the  same  circumstances 
nearly  in  which  it  occurs  in  the  filamentous  tissue.  Thus  it  has 
been  seen  in  land  and  sea  scurvy.  Huxham  observed  it  in  fevers 
with  petechial  eruptions.  And  Cleghorn  states  that  one  of  the  ap- 
pearances after  death  in  the  continuous  and  malignant  tertians  of 
Minorca  was  extravasation  of  blood  in  the  form  of  black  patches 
in  the  adipose  layer  of  the  mesentery,  omentum,  and  colon. 

3.  Excessive  Deposition.  In  certain  subjects,  and  in  peculiar 
circumstances,  the  quantity  deposited  is  enormous.  The  average 
weight  of  the  human  subject  at  a medium  size  is  about  160  pounds, 
or  between  eleven  and  twelve  stones.  Yet  instances  are  on  record 
of  its  attaining  by  deposition  of  fat  in  the  adipose  membrane  the 
extraordinary  weight  of  510,  and  600  pounds,  or  from  thirty-five 
to  forty  stones.  Cheyne  mentions  a case  in  which  the  weight  was 
448  pounds,  equal  to  thirty-two  stones.  In  the  Philosophical 

Transactions  are  recorded  two  cases  of  persons  so  corpulent,  that 

4 


ADIPOSE  TISSUE. 


71 


one  weighed  480  pounds,  and  another  500  pounds.  And  the  Bres- 
lau Collections  contain  cases  in  which  the  human  body  weighed 
580  and  600  pounds. 

In  females  and  in  eunuchs  it  is  more  abundant  than  in  males ; 
in  females  deprived  of  the  ovaries  it  is  more  abundant  than  in  those 
possessed  of  these  organs ; and  it  is  well  known  that  sterility  is  fre- 
quent among  the  corpulent  of  both  sexes.  In  some  circumstances 
this  accumulation  may  be  so  great  as  to  constitute  disease,  {Poly- 
sarcia  adiposa^  Cyrilli,  Sauvages,  Cullen,  and  Good;)  and  in  other 
circumstances  the  deposition  of  fat  is  a means  which  the  secret- 
ing system  seems  to  employ  to  relieve  fulness  and  tension  of  the 
vessels,  and  if  not  to  cure,  at  least  to  obviate  morbid  states  of  the 
circulation.  (Parry.)  Accumulations  of  fat  are  said  to  take  place 
in  some  animals  in  a few  hours  in  certain  states  of  the  atmosphere. 
During  a fog  of  twenty-four  hours’  continuance,  thrushes,  wheat- 
ears,  ortolans,  and  red-breasts  are  reported  to  become  so  fat  that 
they  are  unable  to  fly  from  the  sportsman.  (Bichat.) 

4.  Local  Hypertrophy.  The  adipose  membrane  is  liable  to  a form 
of  hypertrophy,  local  in  situation,  and  of  a peculiar  character.  The 
surface  of  the  person  and  extremities  presents  many  small  tumours, 
varying  in  size  from  a garden  pea  to  that  of  a filbert,  soft,  com- 
pressible, movable  under  the  skin,  and  indolent.  In  some  the  sur- 
face acquires  a bluish  tint,  apparently  from  compression  of  the  ves- 
sels of  the  skin.  In  the  most  marked  case  of  this  which  I have 
seen,  the  number  was  very  considerable,  probably  not  less  than 
eighty  or  ninety  of  different  sizes.  On  inspection  after  death,  which 
was  the  consequence  of  another  disease,  these  bodies  were  found  to 
consist  of  globular  or  spheroidal  masses  of  fat,  not  different  from 
that  of  the  ordinary  fat,  contained  within  membranous  capsules, 
with  walls  a little  firm.  The  individual  was  corpulent ; but  the 
presence  of  these  bodies  seemed,  from  the  account  of  his  medical 
attendants,  to  exert  no  appreciable  influence  on  the  state  of  his 
health. 

These  bodies  appear  to  be  merely  the  result  of  hypertrophy  af- 
fecting many  separate  points  of  the  adipose  membrane. 

5.  Extreme  Diminution.  The  diminution  or  disappearance  of 
fat  is  much  more  frequent  than  its  extraordinary  abundance.  This 
diminution  is  said  to  depend  on  one  or  other  of  the  following 
causes.  Is^,  Long  abstinence,  as  in  fasting,  and  the  periodical 
sleep  of  dormant  and  hybernating  animals ; 2r/,  Organic  diseases, 


72 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


as  consumption,  cancer,  disease  of  the  liver,  especially  cirrhosis, 
disease  of  the  heart,  granular  degeneration  of  the  kidneys,  ulcera- 
tion of  the  intestines,  &c. ; 3c?,  Purulent  collections  or  secretions  ; 
Ath,  Leucophlegmatic  and  dropsical  states ; 5tli,  Gloomy  and  me- 
lancholy thoughts  or  passions  ; Qth,  Long  and  uninterrupted  effort 
of  the  intellectual  powers  ; 1th,  Preternatural  increase  of  the  na- 
tural evacuations,  as  in  cholera,  diarrhoea,  diabetes,  &c.  mucous 
discharges,  especially  from  the  pulmonary  and  intestinal  mem- 
branes, as  in  chronic  catarrh,  inflammation  of  the  intestines  and 
dysentery  ; 8?/<,  Long  and  intense  heat,  whether  natural,  as  during 
hot  summers,  or  artificial,  as  in  furnaces,  hot-houses,  &c. ; 9th, 
Running,  riding,  and  every  species  of  fatiguing  exercise  long  con- 
tinued, as  is  exemplified  in  the  case  of  grooms  at  Newmarket, 
Doncaster,  &c. ; 10?7«,  States  of  long  disease  not  organic;  Wth, 
Night- watching  and  want  of  sleep  in  general  ; \2th.  Immoderate 
use  of  spirituous  liquors  ; 1 Zth,  Habit  of  eating  bitter  and  spiced 
or  acid  aliments. 

Yet  even  in  these  states  the  fat  of  the  animal  body  is  seldom  en- 
tirely wasted.  In  several  organic  diseases,  in  which  great  ema- 
ciation takes  place,  a considerable  quantity  of  fat  is  always  found 
in  the  orbits  behind  the  eyeball,  round  the  substance  of  the  heart, 
around  the  kidneys,  in  the  colon,  and  in  the  mesentery  and  omen- 
tum.* According  to  the  observation  of  William  Hunter,  anasar- 
cous  dropsy  is  the  only  disease  in  which  the  fat  of  the  adipose  mem- 
brane is  entirely  consumed.  “ This  disorder,  when  inveterate,  has 
that  effect  in  such  a degree,  that  we  find  the  heart  or  mesentery  of 
such  subjects  as  free  from  fat  as  in  the  youngest  childi’en.”  This, 
however,  is  in  some  degree  denied  by  Bichat,  who  contends  that  it 
is  not  uncommon  to  find  much  subcutaneous  fat  in  subjects  greatly 
infiltrated,  (Vol.  I.  p.  57.)  It  is  obvious  that  much  will  depend  on 
the  stage  of  the  disease.  It  cannot  be  expected,  that  the  moment 
serous  infiltration  appears  in  the  filamentous  tissue,  all  the  fat 
should  be  at  once  removed  from  the  adipose.  The  process  of  ab- 

■*  An  instance  of  this,  which  occurred  within  the  last  few  days,  may  be  now  men- 
tioned. I had  occasion  to  examine  the  body  of  a young  gentleman,  (3d  October 
1827,)  who  had  laboured  under  symptoms  of  pulmonary  disease  during  the  three 
months  previous  to  his  death.  Though  the  left  lung  was  completely  occupied  with 
small  whitish  amorphous  masses  of  tubercular'  matter  of  different  degrees  of  consist- 
ence, and  the  right  lung  in  addition  to  this  was  in  the  second  stage  of  pulmonic  in- 
flammation, yet  a considerable  layer  of  fat  was  found  between  the  skin  and  muscles  on 
the  chest  and  belly. 


ADIPOSE  TISSUE. 


73 


sorption  is  gradual  as  that  of  deposition ; and  the  inference  of  Hun- 
ter may  be  regarded  as  nearly  exact  in  reference  to  long  continued, 
or  what  he  terms  inveterate  dropsy.  It  is  certain,  that,  while  it  is 
very  difficult  to  deprive  the  bones  of  ordinary  subjects  of  oil,  those 
of  dropscal  subjects  are  the  only  ones  which  it  is  possible  to  obtain 
free  from  this  substance. 

Lastly,  I have  to  observe,  that  the  remark  of  Dr  Hunter  is  appli- 
cable chiefly  to  granular  disease  of  the  kidney,  which,  whether  ac- 
companied with  anasarca  or  not,  has  a remarkable  effect  in  re- 
moving: the  fat  and  various  other  animal  substances. 

The  removal  of  the  fat  from  its  containing  membrane  is  effected 
by  the  process  of  absorption,  the  agents  of  which  are  supposed  by 
William  Hunter,  Portal,  Bichat,  and  Mascagni,  to  be  the  lym- 
phatics. According  to  the  results  of  the  experiments  of  Magendie, 
Mayer,  Tiedemann  and  Gmehn,  Segalas,  &c.  it  must,  in  some 
measure  at  least,  be  ascribed  to  the  influence  of  minute  veins.  It 
is  a point  of  some  interest  to  know  in  what  form  it  is  absorbed, 
whether  as  oily  matter,  or  after  undergoing  a process  of  decompo- 
sition. The  observation  of  Hewson,  of  Dr  Traill,  and  Dr  Christison, 
above  quoted,  would  lead  to  the  former  view ; but  it  is  not  easy  to 
conceive  that  this  should  be  uniform.  W'e  want,  in  short,  correct 
facts  on  the  point  at  issue. 

5.  Adipose  Sarcoma.  This  consists  in  an  unusual  deposition  of 
firm  fatty  matter  in  cells,  the  component  fibres  of  which  are  suffi- 
ciently firm  to  give  its  consistence.  The  tumour,  which  is  gene- 
rally globular,  is  always  surrounded  by  a thin  capsule  formed  by 
the  condensation  of  the  contiguous  filamentous  tissue.  The  tumour 
is  supplied  by  a few  blood-vessels,  which  proceed  from  the  capsule, 
but  which  form  so  slender  an  attachment  that  they  are  readily 
broken,  and  the  tumour  is  easily  scooped  from  its  seat.  This  sort 
of  tumour  occurs  almost  invariably  in  the  adipose  membrane,  and 
seems  to  consist  in  a local  hypertrophy  of  the  part  in  which  it  is 
found.  It  may  have  a broad  basis,  but  is  often  pendulous,  or  at- 
tached by  a narrow  neck  or  stalk.  It  is  the  most  common  form  of 
sarcomatous  tumour,  and  may  occur  in  any  part  of  the  body  in 
which  there  is  adipose  membrane,  but  is  chiefly  found  on  the  front 
and  back  of  the  trunk,  and  not  unfrequently  on  two  places  at  the 
same  time. 

6.  Steatomu.  In  adipose  sarcoma  the  adipose  matter  is  deposit- 
ed in  cells,  and  the  tumour  derives  a degree  of  firmness  from  the 


74 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


fibres  with  which  it  is  thus  traversed  in  every  direction.  In  other 
instances,  however,  the  adipose  matter  is  deposited  in  a mass  in  the 
cavity  of  a spherical  or  spheroidal  cyst,  formed  in  the  filamentous 
or  the  adipose  tissue ; and  the  tumour  is  soft  and  compressible,  and 
seems  to  contain  fluid  or  semifluid  matter.  When  cut  open  it  is 
found  to  contain  a soft  semifluid  matter  of  the  consistence  of  honey, 
but  of  oily  or  adipose  properties.  In  such  circumstances  the  inner 
surface  of  the  cyst,  or  at  least  the  vessels  of  this  surface,  are  the 
agents  which  secrete  the  fatty  matter.  This  tumour  may  occur 
either  in  the  filamentous  or  the  adipose  tissue ; but  is  to  be  re- 
garded as  an  example  of  local  deposition  of  adipose  matter.  It 
may  appear  in  any  region  of  the  filamentous  tissue,  but  is  most 
frequent  about  that  of  the  head  and  face.  Small  steatoms  are  not 
unfrequent  in  the  eyelids  and  in  the  scalp.  Larger  ones  are  more 
frequent  about  the  neck. 

The  other  forms  of  encysted  tumours,  distinguished  hy  the  names 
of  atheroma,  pulticula  ah  ada^a,  pultis  genus),  and  meliceris 

(iOE.2X/K>)g/?  mel  and  cera,  honey  ; wax),  are  to  be  viewed  ratber  as  va- 
rieties of  the  steatom  than  as  generically  different.  The  substance 
contained  may  differ  in  consistence,  but  is  nearly  the  same  in  es- 
sential qualities. 

7.  Melanosis.  I have  already  spoken  of  the  melanotic  deposi- 
tion taking  place  in  the  filamentous  tissue.  The  adipose  mem- 
brane is  also  a frequent  seat  of  this  singular  change.  The  black 
or  melanose  matter  is  found  in  the  subcutaneous  adipose  membrane 
and  the  subjacent  cellular  tissue  of  the  chest  and  belly ; it  is  not 
uncommon  in  the  fat  of  the  orbit ; it  is  very  commonly  seen  in  the 
adipose  cushion  on  the  fore-part  of  the  vertebral  column,  that  sur- 
rounding the  kidneys,  and  in  the  fat  of  the  anus  and  rectum  ; it  is 
found  in  the  anterior  and  posterior  mediastinum ; and  it  is  found 
between  the  folds  of  the  mesentery,  of  the  mesocolon,  and  of  the 
omentum.  It  is  also  found  in  the  substance  of  the  marrow  of 
bones ; and  perhaps  in  most  cases  in  which  the  osseous  system  ap- 
pears to  be  stained  with  the  melanose  deposite,  the  dark  matter  may 
be  traced  to  the  medullary  particles,  the  situation  of  which  it  is 
found  accurately  to  occupy. 

In  all  these  situations  it  appears  in  various  degrees  of  perfection, 
and  in  different  forms.  It  may  be  disseminated  in  black  or  inky 
spots  through  the  adipose  membrane ; it  may  be  accumulated  in 
spherical  or  spheroidal  masses  of  various  size  and  shape ; or  it  may 


ARTERY,  ARTERIAL  TISSUE. 


75 


be  found  in  the  form  of  brown  or  ebon-coloured  fluid  or  semifluid, 
enclosed  in  a cyst  formed  of  the  contiguous  tissue  more  or  less 
condensed. 

The  melanose  matter  is  entirely  destitute  of  organization,  and  is 
to  be  regarded  as  the  result  of  a peculiar  secretion.  No  vessels 
have  been  traced  into  it ; and  when  bodies  afiected  with  this  de- 
posite  are  minutely  injected,  the  vessels  can  be  traced  no  farther 
than  the  enveloping  cyst.  (Breschet.)  It  is  also  to  be  noticed  that 
it  is  never  deposited  exactly  in  the  site  of  organic  flbres,  but  always 
between  them,  and  very  generally  in  the  precise  situation  of  the 
adipose  particles.  These  several  circumstances  show  that  the  me- 
lanose disease  consists  not  in  a degeneration  or  conversion  into 
another  substance,  but  in  the  deposition  of  a new  form  of  matter 
in  the  manner  of  a secretion. 

In  what  form  the  melanose  substance  is  first  deposited  we  have 
few  accurate  facts  to  enable  us  to  form  a judgment.  Laennec  is 
of  opinion  that  it  is  first  deposited  in  a solid  form,  and  afterwards 
becomes  fluid.  The  former  he  considers  the  stage  of  crudity,  the 
latter  that  of  softening,  {ramoUissemenL')  Several  facts,  however, 
would  lead  to  the  conclusion,  that  when  first  deposited  it  was  fluid, 
and  afterwards  acquired  consistency.  Thus,  in  several  dissections 
performed  by  Dr  Cullen  and  Mr  Carsewell,  the  matter  of  the  small 
tumours,  which  are  supposed  to  be  of  short  duration,  were  found 
to  be  softest,  and  sometimes  as  fluid  as  cream.*  In  like  manner, 
in  a case  recorded  by  M.  Chomel,  in  which  the  disease  was  found 
in  the  liver  in  the  shape  of  large  cysts,  the  melanose  matter  was 
more  fluid  in  the  centre  than  in  the  circumference  of  the  cysts.f 
Upon  the  whole,  if  the  melanose  deposite  be,  as  is  supposed,  an  in- 
organic secretion,  the  idea  of  its  being  poured  forth  from  the  ves- 
sels at  first  in  a fluid  or  semifluid  state  is  most  probable,  and  most 
consistent  with  the  usual  phenomena  and  laws  of  animal  pro- 
cesses. 

8.  Acephalo-cysts.  This  form  of  hydatid  is  occasionally  found  si- 
tuate beneath  the  skin,  partly  in  the  adipose  tissue,  partly  in  the 
cellular  membrane.  When  present  in  numbers,  they  form  an  ex- 
tensive superficial  tumour  over  the  person,  most  commonly  the 
back,  and  in  rare  cases  in  the  extremities.  They  present  the  usual 
characters  of  acephalo-cysts  in  other  regions ; that  is,  they  are  glo- 

* Transactions  of  the  Medico-Chirurgical  Society  of  Edinburgh,  Vol.  I.  p.  264. 

■f  Nouveau  Journal  de  Medecine,  Tome  III.  p.  41. 


76 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


bular  cysts,  sometimes  solitary,  more  frequently  associated  or  con- 
gregated with  membranous  coverings,  thin,  opaque,  and  almost 
translucent.  In  some  instances  they  give  rise  to  suppuration,  and 
by  this  means  come  to  the  surface.  If  they  do  not,  they  seem  to 
cause  inconvenience  by  their  size,  number,  and  situation.  One 
incision  made  through  the  skin  often  allows  the  escape  of  a great 
number,  leaving  an  extensive  cavity  in  the  adipose  and  cellular 
membrane. 

9.  Induration.  I think  it  probable  that  the  peculiar  affection  which 
takes  place  in  the  bodies  of  infants  described  at  p.  43  in  chapter  iii. 
should  be  referred  to  this  tissue.  But  after  this  mention  of  the  sub- 
ject, I think  it  unnecessary  to  alter  the  arrangement. 


CHAPTER  V. 

ARTERY,  ARTERIAL  TISSUE,  {Artcvia, — Tissu  arterid.) 

Section  I. 

The  structure  of  the  arteries  has  been  so  much  the  subject  of 
examination  at  all  periods  of  the  history  of  anatomy,  that  to  men- 
tion the  authors  by  whom  it  has  been  described  would  be  much  the 
same^  as  to  enumerate  all  the  anatomists  who  have  ever  written. 
To  omit  Galen,  and  some  of  those  who  wrote  shortly  after  the  re- 
vival of  literature,  descriptions  of  the  structure  of  arteries  have 
been  given  with  different  degrees  of  minuteness  and  accuracy  by 
Willis,  Vieussens,  Verheyen,  Lancisi,  Bldloo,  the  first  Monro, 
Morgagni,  Ludwig,  Haller,  De  La  Sone,  Bichat,  Gordon,  Magen- 
die,  and  by  Mondini.  Yet  the  descriptions  given  by  these  observ- 
ers are  so  discordant,  that  Ludwig  complains  of  the  difficulty  of  re- 
conciling them,  and  Haller  evidently  felt  it ; and  with  the  excep- 
tion of  those  given  by  the  four  last  authors,  they  do  not  accord  with 
the  characters  which  this  substance  actually  presents. 

The  following  account  is  derived  principally  from  repeated  ex- 
amination of  the  arteries  of  the  human  subject,  occasionally  com- 
pared with  those  of  the  more  familiar  domestic  animals. 

Every  arterial  tube  greater  than  one  line  in  diameter  is  visibly 
composed  of  one  adventitious  and  two  essential  substances.  The 


ARTERY,  ARTERIAL  TISSUE. 


77 


first,  the  sheath,  reputed  to  consist  of  condensed  filamentous  tissue : 
the  two  last,  the  proper  arterial  and  internal  tissues.  ( Tunica  pro- 
pria et  membrana  intima.') 

1.  The  inner  surface  of  the  arterial  tube  is  formed  by  a very 
thin  semitransparent  polished  membrane,  which  is  said  to  extend 
not  only  in  the  one  direction  over  the  inner  surface  of  the  left  ven- 
tricle, auricle,  and  pulmonary  veins,  but  in  the  other  to  form  the 
minute  vascular  terminations  which  are  distributed  through  the 
substance  of  the  different  organs.  This  membrane  is  particularly 
described  by  Bichat  under  the  name  of  common  membrane  of  the 
system  of  red  blood,  because  he  believed  it  to  exist  wherever  red 
blood  was  moving, — in  the  pulmonary  veins,  in  the  left  side  of  the 
heart,  and  over  the  entire  arterial  system. 

The  inner  membrane  may  be  demonstrated  by  cutting  open  or 
inverting  any  artery  of  moderate  size,  when  it  may  be  peeled  oflf  in 
the  form  of  thin  slips  by  the  forceps.  Or,  if  the  tube  be  fitted  on 
a glass  rod,  by  removing  the  layers  of  the  proper  membrane  in  suc- 
cessive portions,  the  inner  one  at  length  comes  into  view  in  the 
form  of  a thin  translucent  pellicle,  of  uniform,  homogeneous  aspect, 
without  fibres  or  other  obvious  traces  of  organization.  This  mem- 
brane is  supposed  to  be  prolonged  to  form  those  minute  vessels  in 
which  the  proper  coat  cannot  be  traced.  It  is  very  brittle,  and  is 
distinguished  during  life  by  a remarkable  activity  in  forming  the 
morbid  states  to  which  arteries  are  liable.  In  other  respects  it  is 
deemed  by  Bichat  peculiar,  and,  though  similar  to  the  proper  mem- 
brane, is  to  he  considered  as  unlike  any  other  tissue.  Its  chemical 
composition  is  not  known. 

2.  Exterior  to  this  common  or  inner  membrane  is  placed  a dense 
strong  tissue  of  considerable  thickness,  of  a dun  yellowish  colour, 
which  is  found  to  consist  of  fibres  disposed  in  concentric  circles 
placed  contiguous  to  each  other  round  the  axis  of  the  artery.  If 
this  substance  be  examined  either  from  without  or  in  the  opposite 
direction,  it  will  be  found  that,  by  proper  use  of  forceps,  its  fibres 
can  be  separated  to  an  indefinite  degree  of  minuteness,  even  to  that 
of  a hair,  and  that  they  uniformly  separate  in  the  same  direction. 
Longitudinal  fibres  are  visible  neither  in  this  nor  in  any  other  tis- 
sue of  the  arterial  tube.  This  is  the  proper  arterial  tissue,  {tunica 
propria.)  Its  uniform  dun  yellow  colour  is  perceived  through  the 
semitransparent  inner  membrane,  and  is  most  conspicuous  either 
when  this  is  removed,  or  when  the  outer  cellular  envelope  is  de- 


78 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


tached  and  the  component  threads  separated  from  each  other ; and 
if  it  be  less  distinct  in  the  smaller  branches,  it  is  because  the  tissue 
on  which  the  colour  depends  is  here  considerably  thinner.  In  this 
respect  it  varies  in  different  regions.  Though  in  general  less  dense 
and  abundant  as  the  arteries  recede  from  the  heart,  it  is  thicker, 
cateris  paribus^  in  those  of  the  lower  than  in  those  of  the  upper  ex- 
tremities. In  the  vertebral  and  internal  carotid  arteries,  and  in 
those  distributed  in  the  substance  of  the  liver,  spleen,  &c.  it  is 
thinner  than  in  vessels  of  the  same  size  in  the  muscular  interstices. 

The  nature  of  this  tissue  has  been  the  subject  of  much  contro- 
versy. It  was  long  believed  to  be  muscular,  and  to  possess  the  pro- 
perties of  muscular  fibre.  Bichat  showed  that  the  arguments  by 
which  this  opinion  was  supported  are  inconclusive,  and  that  the  ar- 
terial tissue  has  very  few  qualities  in  common  with  the  muscular. 
The  circumstances  from  which  he  derived  his  proofs  were  its  phy- 
sical and  physiological  properties. 

The  arguments  derived  from  the  physical  properties  of  this  tis- 
sue are  chiefly  the  following.  The  arterial  tissue  is  close,  elastic, 
fi’agile,  and  easily  divided  by  ligature ; muscular  fibre  is  more  loose 
in  structure,  by  no  means  elastic,  and,  instead  of  being  divided  or 
cut  by  ligature  as  artery  is,  undergoes  a sort  of  strangulation. 
The  action  of  alcohol,  diluted  acids,  and  caloric,  by  means  of  hot 
fluids,  which  are  not  corrosive,  affords  a proof  of  the  chemical  dif- 
ference of  these  animal  substances.  All  of  them  produce,  in  the 
arterial  tunic,  a species  of  shrivelling  or  crispation,  which  seems  to 
depend  on  more  complete  coagulation  of  one  of  the  chemical  prin- 
ciples ; but  no  similar  effect  takes  place  in  muscular  fibres.  Ac- 
cording to  Berzelius  the  proper  arterial  tunic  contains  no  fibrine.* 
Bedard,  however,  asserts,  that  he  has  ascertained  that  it  contains 
a portion  of  this  principle ; but  nevertheless  hesitates  to  consider  it 
as  a muscular  or  fibrinous  tissue,  and  expresses  his  opinion,  that  it 
would  be  with  greater  propriety  referred  to  that  order  of  substan- 
ces which  he  has  named  yellow  or  tawny  fibrous  system. 

The  consideration  of  the  physiological  or  organic  properties  leads 
to  similar  results.  Neither  mechanical  or  chemical  agents  applied 
as  stimulants  produce  any  change  or  motion  in  tlie  living  arterial 
membrane.  1.  The  arteries  of  an  amputated  limb,  exposed  the 
moment  after  amputation,  while  the  muscles  are  in  active  motion, 

* A View  of  the  Progress  of  Animal  Chemistry.  By  J.  J.  Berzelius,  M.  D.  &c.  &c. 
London,  1813.  Pp.  24,  25. 


ARTERY,  ARTERIAL  TISSUE. 


79 


do  not  contract  or  move  when  punctured  by  the  scalpel.  2.  The 
experiments  of  Bikker  and  Van-den-Bos  with  the  electric  spark, 
and  those  of  Vassalli-Eandi,  Griulio,  and  Rossi  with  the  galvanic 
pile,  may  be  considered  as  disproved  by  the  experiments  of  Nysten,* 
who  found  no  contraction  in  the  human  aorta  after  violent  death, 
while  the  heart  and  other  muscles  could  still  be  excited.  In  per- 
forming the  same  experiment  with  the  artery  of  the  living  dog  this 
physiologist  was  equally  disappointed.  3.  The  circular  contraction 
of  the  calibre  of  an  artery,  either  partially  or  wholly  divided,  de- 
pends not  on  irritability,  but  either  on  its  elasticity,  or  on  that  pro- 
perty which  it  possesses  of  contracting  strongly,  the  instant  the  dis- 
tending agent  is  removed.  This  power,  which  was  rather  happily 
named  by  Bichat  contractUite  par  defaut  extension,  is  qiute  differ- 
ent from  muscular  contraction  or  irritability,  and  must  not  be  con- 
founded with  them ; but  it  depends  in  a degree  not  much  less  on 
the  living  state  of  the  body  and  the  individual  arterial  tube.  4. 
The  contraction  said  to  take  place  in  living  arteries  after  the  appli- 
cation of  alcohol,  acids,  or  alkalis,  is  to  be  ascribed  to  the  chemical 
crispation,  and  not  to  stimulant  power.  It  does  not  relax.  5. 
These  inferences  are  not  inconsistent  with  the  experiments  of  Thom- 
son, Philips,  Hastings,  and  Kaltenbrunner,  on  minute  arterial  tubes, 
which  may  be  admitted  to  possess  something  like  irritability,  or  ra- 
ther susceptibility  of  contraction,  without  the  necessity  of  supposing 
the  same  property  in  the  large  branches  and  trunks.  6.  This  is  so 
much  more  probable,  as  in  these  minute  arteries  the  proper  arte- 
rial tunic  is  either  wanting,  or  is  so  much  thinner  and  so  modified, 
that  it  is  impossible  to  conceive  its  presence  capable  of  affecting  the 
result  of  experiments  made  to  deterraime  the  degree  or  kind  of  ar- 
terial contraction. 

3.  The  outer  surface  of  the  proper  arterial  tissue  is  enveloped, 
as  above  noticed,  in  a layer  of  dense  filamentous  or  cellular  mem- 
brane, which  is  very  firmly  attached  to  it,  and  which  was  formerly 
considered  as  part  of  the  arterial  tissue.  It  is  adventitious ; a mo- 
dification of  filamentous  or  cellular  texture  which  establishes  a com- 
munication between  the  artery  and  the  contiguous  parts,  and  is  ne- 
cessary to  the  nutrition  and  healthy  state  of  the  vessel.  It  incloses 
and  transmits  the  minute  vessels  anciently  denominated  vasa  vaso- 
rum,  {arteriolce  arteriarum,  Haller  ;)  and  if  detached  even  through 

* Nouvelles  Experiences  Galvaniques,  &c.  Par  P.  H.  Nysten,  &c.  A Paris,  An. 
XL  pp,  235  and  236. 


80 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


a trifling  extent,  the  arterial  portion  thus  isolated  is  sure  to  become 
dead  ; to  be  affected  with  inflammatory  and  sloughing  action ; and 
ultimately  to  give  way  and  discharge  the  contents  of  the  vessel.  M. 
Bedard  considers  it  a fibro-cellular  membrane,  which  may  in  the 
larger  arteries  be  divided  into  two  layers,  one  exterior,  similar  to 
the  general  filamentous  tissue  ; the  other  inside  between  the  outer 
layer  and  the  proper  tissue,  yellowish  and  firm,  but  still  sufficiently 
distinct  from  the  proper  tunic.  In  the  cerebral  arteries  it  is  want- 
ing, and  in  most  parts  of  the  chest  and  belly  its  absence  is  supplied 
by  a portion  of  pericardium,  pleura,  or  peritonaeum.  Yet  even 
there  a thin  layer  of  fine  cellular  tissue  appears  to  connect  these 
membranes  to  the  proper  tunic.  In  the  extremities  the  cellular 
sheath  is  removed  in  dissecting  arterial  preparations. 

At  different  periods  several  anatomists  have  maintained  the  ex- 
istence of  longitudinal  fibres  in  arterial  tissue  ; and  even  at  the  pre- 
sent day  this  notion  is  not  entirely  abandoned.  Morgagni  was  the 
first  who,  trusting  to  mere  observation,  the  only  sure  guide  in  ana- 
tomical science,  doubted  the  existence  of  these  fibres,  and  was  not 
ashamed  to  say  he  was  unable  to  perceive  them.*  Upon  the  same 
ground  Haller  would  not  admit  their  existence  ;f  and  Bichat  and 
Meckel  positively  deny  them.  I have  repeatedly  examined  almost 
every  considerable  artery  of  the  human  body,  and  I have  never 
been  able  to  recognize  any  longitudinal  fibres  either  in  the  middle 
or  proper  coat,  or  in  the  thin  internal  membrane,  as  taught  by 
Willis,  Douglas,  and  De  La  Sone. 

Though  arterial  tissue  does  not  appear  to  be  very  vascular,  it  is 
furnished  with  arteries  and  veins  {yasa  vasormn  ; arterioles  arteria- 
rum,)  which  do  not  come  from  the  artery  or  vein  itself,  hut  from  the 
neighbouring  vessels.^  Thus  the  aorta  at  its  origin  is  supplied  with 
minute  arteries  from  the  right  and  left  coronary,  and  in  some  in- 
stances with  a proper  vessel  adjoining  to  the  orifice  of  the  right  co- 
ronary artery,  which  Haller  regards  as  a third  coronary.  The  rest 
of  the  thoracic  aorta  derives  its  vessels  from  the  upper  bronchials, 
from  twigs  of  the  internal  mammary  arteries,  from  the  bronchials, 
from  the  oesophageals,  and  from  the  phrenics.  The  abdominal  por- 

* Adversaria  Anatomica,  II.  23-  78. 

t “ Verum  anatome  et  microscopium  omnino  fibres  longitudinem  seqiientes  num- 
quam  demonstravit,  aut  mihi,  aut  aliis,  ante  me,  scriptoribus,  quorum  auctoritate 
meam  tueor.” — Elementa,  Lib.  ii.  sect.  1,  sect.  7. 

+ Hunter,  IV.  p.  131. 


3 


AliTERY,  ARTERIAL  TISSUE. 


81 


tion  is  supplied  from  the  spermatics,  the  lumbar,  and  in  some  in- 
stances the  mesocolic  artery.  The  same  arrangement  nearly  is 
observed  with  regard  to  the  veins. 

Few  textures  are  more  liberally  supplied  with  nerves  than  arte- 
ries are.  Almost  every  considerable  trunk  or  vessel  is  surrounded 
with  numerous  plexiform  filaments  of  nerves,  many  of  which  may 
be  traced  into  the  tissue  of  the  artery.  The  anterior  part  of  the 
arch  of  the  aorta  is  abundantly  supplied  with  branches  from  the 
superficial  cardiac  nerves,  which  Haller  was  unable  to  trace  beyond 
the  artery.  The  coeliac,  the  mesenteric,  and  the  mesocolic  arteries 
are  invested  with  numerous  plexiform  nervous  filaments  derived 
from  the  large  semilunar  ganglion  of  the  splanchnic  nerve.  The 
renal  arteries  in  like  manner  are  surrounded  with  numerous  twigs 
of  the  renal  plexus.  And  each  of  the  intercostal  arteries  at  its 
origin  receives  nervous  threads  from  the  intercostal  nerves.  In  the 
face  the  branches  of  the  fifth  pair  may  often  be  traced  enveloping 
the  arteries.  This  arrangement,  which  is  observed  chiefly  in  the 
blood-vessels  going  to  the  internal  organs,  led  Bichat  to  announce 
it  as  a general  fact,  that  the  arteries  derived  their  nerves  almost 
exclusively  from  the  ganglions,  and  the  gangliar  nerves.*  The 
inference  does  not  rest  upon  strict  observation,  and  evidently  owes 
its  birth  to  the  hypothetical  opinions  of  this  ingenious  physiologist. 
All  the  arteries  going  to  the  extremities,  the  axillary,  and  iliac,  and 
their  branches,  receive  nerves  from  the  neighbouring  nervous 
trunks,  which  are  formed  chiefly  from  cerebral  or  spinal  nerves, 
and  have  no  immediate  connection  with  the  system  of  the  ganglions. 
In  the  internal  carotid  and  the  vertebral  arteries,  and  their  branches, 
nerves  cannot  be  distinctly  traced.f 

Organized  in  the  manner  now  described,  it  is  requisite  to  take  a 
short  view  of  the  anatomical  connections  of  the  arterial  system,  or 
to  consider  it  in  its  origin,  its  course,  and  its  termination. 

The  arterial  system  of  the  animal  body  may  be  viewed  as  one 
large  trunk  divided  into  several  branches,  which  again  are  subdi- 
vided and  ramified  to  a degree  of  minuteness  which  exceeds  all 
calculation.  It  is  requisite,  therefore,  to  consider  the  origin,  Is^,  Of 
the  aorta,  the  large  trunk  ; 2d,  Of  the  branches  wliich  arise  from 
it ; and,  Zdly,  Of  the  small  vessels  into  which  these  are  divided. 


* “ Le  grand  arbre  a sang  rouge  ou  I’arteriel,  est  presque  exclusivement  embrasse 
par  la  premiere  classe  des  nerves.” — Anatomie  General,  Tom.  I.  p.  302. 

■f  H.  A.  WrisbergDe  Nervis  Arterias  Venasque  comitantibus,  Tome  III. 

F 


82 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Every  one  knows  that  the  aorta  is  connected  at  its  origin  with 
the  upper  and  anterior  part  of  the  left  ventricle.  The  manner  of 
this  connection  has  been  well  examined  by  Lancisi,  by  Ludwig,  and 
particularly  by  Bichat.  It  may  be  demonstrated  by  dissection,  but 
is  much  more  distinctly  shown  by  boiling  the  heart  with  the  blood- 
vessels attached.  In  a heart  so  treated  the  thin  internal  membrane 
may  he  traced  passing  from  the  interior  of  the  ventricle  along  the 
margin  of  its  orifice  to  the  inside  of  the  arterial  tube.  Exactly  at 
the  point  of  union  it  is  doubled  into  three  semicircular  folds,  form- 
ing semilunar  valves,  and  thence  is  continued  along  the  whole 
course  of  the  artery.  This  membrane  is  entirely  distinct  from  the 
proper  or  fibrous  coat.  Of  the  latter,  the  cardiac  extremity  or  be- 
ginning is  notched  into  three  semicircular  sections,  each  of  which 
corresponds  to  the  base  or  attached  margin  of  a semilunar  valve. 
These  sections  are  attached  to  the  aortic  orifice  of  the  ventricle  by 
delicate  filamentous  tissue,  but  are  not  connected  with  the  fleshy 
fibres  of  the  heart ; and  at  the  angle  or  point  of  attachment,  the 
thin  inner  membrane  is  folded  in  so  as  to  fill  up  a space  or  interval 
which  is  left  between  the  margin  of  the  orifice  and  the  circumfe- 
rence of  the  proper  arterial  tissue,  where  it  is  notched  or  trisected. 

The  aorta  is  soon  divided  into  branches,  which  again  are  subdi- 
vided into  small  vessels.  With  the  mathematical  physiologists,  it 
was  a favourite  problem  to  ascertain  the  number  of  branches  into 
which  any  vessel  might  be  subdivided.  Keill  made  them  from 
forty  to  fifty.  Haller  states,  that,  counting  the  minutest  ramifica- 
tions, he  has  found  scarcely  twenty.  The  inquiry  is  vain  and  use- 
less, and  cannot  be  subjected  to  accurate  calculation.  In  no  two 
subjects  is  the  same  artery  found  to  be  subdivided  the  same  number 
of  times,  and  in  no  two  subjects  are  the  very  same  branches  found 
to  arise  from  the  same  trunk. 

A branch  issuing  from  a trunk  generally  forms  with  it  a particu- 
lar angle.  Most  generally,  perhaps,  these  angles  are  acute  ; but 
in  particular  situations  they  approach  nearly  to  a right  angle. 
Thus  the  innominata,  left  carotid,  and  left  subclavian,  issue  from 
the  arch  of  the  aorta  nearly  at  a right  angle,  at  least  to  the  tangent 
of  the  arch.  The  intercostals  form  a right  angle  with  the  thoracic 
aorta ; the  renal  and  lumbar  arteries  form  a large  acute  angle, 
approaching  to  right  with  the  abdominal ; and  the  coeliac  comes 
off  nearly  in  the  same  manner  from  the  anterior  part  of  the  vessel. 
The  internal  and  external  carotids,  again,  the  external  and  inter- 


AETEKY,  ARTERIAL  TISSUE. 


83 


nal  iliacs,  the  branches  of  the  humeral,  and  those  of  the  femoral, 
form  angles  more  or  less  acute  with  each  other.  The  angle  which 
the  spermatics  make  is,  generally  speaking,  the  most  acute  in  the 
arterial  system. 

It  is  convenient  to  distinguish  the  branches  and  divisions  of  the 
arterial  system  into  different  classes  or  orders,  according  to  their 
size  and  their  proximity  to,  or  distance  from,  the  heart.  Though 
the  arterial  system  may  be  considered  as  one  single  artery  divided 
and  subdivided  into  a multiplicity  of  branches  and  twigs,  yet  in  re- 
ference to  the  communications  between  the  latter,  they  may  be  dis- 
tinguished into  the  following  orders. 

First  order,  the  aorta  and  innominata ; the  second  order,  the 
common  carotid  arteries,  the  subclavian  arteries,  and  the  common 
iliac  arteries ; the  third  order,  the  external  and  internal  carotid 
arteries,  the  axillary  arteries,  the  external  and  internal  iliac  arte- 
ries ; the  fourth  order,  the  brachial  arteries,  the  femoral  arteries, 
and  the  sacromedian  arteries ; the  branches  of  the  subclavian  and  ax- 
illary trunks,  as  the  vertebrals,  transverse  cervicals,  scapular  arte- 
ries, the  pelvic  and  other  branches  of  the  posterior  and  anterior 
iliac  arteries ; the  fifth  order,  the  superficial  and  deep  brachial  ar- 
teries, the  radial  and  ulnar,  the  superficial  and  deep  femoral  arte- 
ries, the  popliteal,  the  anterior  tibial,  and  posterior  tibial,  and  the 
peroneal  arteries ; and  the  sixth  order,  all  other  small  vessels  be- 
neath the  size  and  capacity  of  those  already  specified. 

This  division  is  useful  in  reference  to  the  phenomena  of  obstruc- 
tion of  arteries,  and  the  means  and  channels  by  which  the  incon- 
veniences of  obstruction  are  compensated.  It  will  be  seen  after- 
wards that  obliteration  or  contraction  of  vessels  of  the  fourth,  fifth, 
and  sixth  orders,  and  obstruction  of  their  canals,  are  evils  much  less 
serious  and  important  than  contraction  or  obliteration  of  vessels  of 
the  first,  second,  and  third  orders.  In  short,  the  functions  of  ar- 
teries in  the  first,  second,  and  third  orders  of  vessels  are  in  this  re- 
spect more  necessary  and  indispensable  than  in  the  three  last  or- 
ders of  vessels.  Hemorrhage,  also,  from  the  first  two  or  three  or- 
ders of  vessels  is  much  more  dangerous  than  from  the  fourth,  and 
from  the  fourth  than  from  the  fifth  or  sixth. 

I have  already  alluded  to  the  structure  of  the  arterial  tissue  at 
the  divarications.  These  changes  relate  both  to  the  inner  and  to 
the  proper  membrane.  In  the  inside  of  the  vessel,  the  inner  mem- 


84 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


brane  is  folded  somewhat  so  as  to  form  a prominent  or  elevated 
point,  the  disposition  of  which  varies  according  to  the  angle  of  di- 
varication. Is#,  When  this  is  rectangular,  the  prominence  of  the 
inner  membrane  is  circular,  and  is  equally  distinct  all  round.  2d, 
When  the  angle  is  obtuse,  as  in  the  mesenteric  artery,  the  promi- 
nence is  distinct,  and  resembles  a semicircular  ridge,  between  the 
continuation  of  the  trunk  and  the  branch  given  off,  but  indistinct 
on  the  opposite  side  where  the  angle  is  obtuse.  3c?,  If  the  angle 
is  acute,  and  that  formed  by  the  branch  with  the  continuation  of 
the  trunk  is  obtuse,  the  beginning  of  the  artery  presents  an  oblique 
circle,  the  elevated  half  of  which  is  near  the  heart,  the  other  more 
remote. 

The  arrangement  of  the  fibres  of  the  jjroper  tissue  is  described 
by  Ludwig  from  the  divarication  of  the  iliac  arteries,  and  may  be 
seen  in  any  part  of  the  arterial  system  where  the  vessels  are  large. 
The  circular  fibres  separating  form  on  each  side  a half  ring,  from 
which  is  produced  a complete  ring  which  incloses  the  smaller  rings 
formed  by  the  circular  fibres  of  the  vessel  given  off.  These  cir- 
cular fibres  proceed  to  the  prominence  of  the  internal  membrane 
already  described,  and  are  arranged  round  it  much  in  the  same 
manner,  in  which  those  of  the  large  vessels  surround  its  inner  mem- 
brane. In  this,  however,  no  continuity  between  the  rings  of  the 
large  vessel  and  those  of  the  small  one  can  be  recognized.  The 
latter  are  inserted  as  it  were  into  the  former,  and  they  are  con- 
nected by  the  continuity  of  the  inner  membrane  only. 

In  observing  the  course  or  transit  of  arterial  tubes,  the  principal 
point  deserving  notice  is  the  sheltered  situation  which  they  gene- 
rally occupy,  their  tortuous  course,  and  their  mutual  communica- 
tions. In  the  extremities  they  are  always  found  towards  the  inte- 
rior or  least  exposed  part  of  the  limb,  generally  deep  between 
muscles,  and  sometimes  lying  along  bones.  When  they  are  mi- 
nutely subdivided,  they  enter  into  the  interior  of  organs,  without, 
however,  sinking  at  once  into  their  intimate  substance.  In  the 
muscles,  they  are  lodged  between  the  fibres ; in  the  brain,  in  the 
convolutions  ; in  glands,  between  their  component  lobes.  In  such 
situations  they  are  generally  observed  to  be  more  or  less  tortuous 
in  the  course  which  they  follow.  On  the  reasons  of  this,  much  dif- 
ference of  opinion  still  prevails.  (Bichat  and  Magendie.) 

In  the  course  of  the  arteries,  no  circumstance  is  of  greater  mo- 

4 


AETERY,  ARTERIAL  TISSUE. 


85 


ment  than  their  mutual  communications  or  inosculations,  (anasto- 
moses.) Of  this  there  may  be  two  forms  ; the  first  when  two  equal 
trunks  unite,  the  second  when  a large  vessel  unites  with  a smaller 
one.  Of  the  first,  three  varieties  have  been  mentioned.  Is^,  Two 
equal  trunks  may  unite  at  an  acute  angle  to  form  one  vessel. 
Thus,  in  the  foetus,  the  ductus  arteriosus  and  the  aorta  are  con- 
joined; and  tbe  two  vertebral  arteries  unite  to  form  the  basilar 
trunk.  2d,  Two  trunks  may  communicate  by  a transverse  branch, 
as  the  two  anterior  cerebral  arteries  do  in  forming  the  anterior 
segment  of  the  circle  of  Willis.  3d,  Two  trunks  may,  by  mutual 
union,  form  an  arcb,  from  the  convexity  of  which  the  minute  ves- 
sels arise,  as  is  seen  in  the  branches  of  the  mesenteric  arteries. 

The  second  mode  of  inosculation  is  frequent  in  the  extremities, 
especially  round  the  joints.  The  multiplied  communications  of  the 
arterial  system  in  these  regions,  though  well  known  to  anatomists, 
and  enumerated  by  Haller,  were  first  clearly  and  systematically 
explained  by  Scarpa,  and  afterwards  by  Cooper  and  Hodgson. 
The  importance  of  this  arrangement  in  facilitating  the  motions  of 
the  circulation,  in  obviating  the  eflfects  of  local  impediment  in  any 
vessel  or  set  of  vessels,  and  in  enabling  the  surgeon  to  tie  an  arte- 
rial trunk  when  wounded,  affected  with  aneurism  or  any  other  dis- 
ease, has  been  clearly  established  by  these  authors.  Their  re- 
searches have  shown  that  there  is  not  a single  vessel  which  may 
not  be  tied  with  full  confidence  in  the  powers  of  the  collateral  circu- 
lation. Even  the  aorta  has  been  found  contracted  or  obliterated, 
and  its  channel  obstructed  in  the  human  subject  in  twelve  instances, 
(Paris,* * * §)  (Graham,t)(Winstone,J)(Otto,§)  (Meckel,||)  (Reynaud,^) 


* Retrecissement  considerable  de  I’Aorte  Pectorale,  observe  a I’Hotel  Dieu  de  Pa- 
ris. Journal  de  Chirurgie.  Par  Desault.  Tome  II.  p.  107.  Paris,  1791. 

•f-  Case  of  Obstructed  Aorta.  By  Robert  Graham,  M.  D.,  Medico-Chirurgical  Trans- 
actions, Vol.  V.  p.  287.  London,  1814. 

X Surgical  Essays.  By  Astley  Cooper,  F.  R.  S.,  and  Benjamin  Travers,  F.  R.  S. 
Part  1.  p.  115.  Third  Edition.  London,  1818. 

§ Neue  Seltene  Beobachtungen  zur  Anatomie,  Physiologie  und  Pathologic  gehorig. 
Von  Adolph  Wilhelm  Otto.  Berlin,  1824.  4to.  Dritter  Abshnitt,  C.  XXIX.  Seite  66. 

II  Verschhessung  der  Aorta  am  Viertel  Brustwirbel.  Von  A.  Meckel  zu  Bern.  Ar- 
chiv  fiir  Anatomie  und  Physiologie.  Herausgegeben  Von  Johan  Friederich  Meckel, 

1827.  Leipzig.  Seite  345. 

^ Observation  dUne  Obliteration  presque  complete  de  PAorte,  &c.  Par  M.  Rey- 
naud.  Journal  Hebdomadaire  de  Medecine,  Tome  Premier,  1828.  P.  161.  Paris 

1828. 


86 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


(Jordan,* * * §)  (Le  Grand, f)  (Nixon, J)  (Craigie,§)  (Eichler  and  Ro- 
mer,  || ) (Tiedemann,^)  ; and  a ligature  has  been  put  on  its  abdominal 
portion,  (Cooper.) 

To  ascertain  the  several  modes  in  which  arteries  terminate  has 
been  a problem  of  much  interest  to  the  physiologist,  and  of  no 
small  difficulty  to  the  anatomist.  The  alleged  terminations  as  be- 
lieved to  be  established,  are  minutely  and  elaborately  enumerated 
by  Haller,  who,  however,  multiplied  them  too  much  according  to 
the  modern  acceptation  of  the  term. 

1.  The  first  undoubted  termination  of  arteries  is  immediately  in 
veins.  It  is  unnecessary  to  adduce  in  support  of  this  fact  the  long 
list  of  observers  enumerated  by  Haller.  It  is  sufficient  to  say  that 
it  was  clearly  established  by  the  microscopical  observations  of  Leu- 
wenhoeck,  Cowper,  and  Baker,  by  Haller  himself,  and  by  Spal- 
lanzani in  his  beautiful  experiments  on  the  circulation  of  the  blood. 

2.  The  second  termination  which  may  he  mentioned  here  is  that 
into  the  colourless  artery,  {arteria  non  rubra.)  This  is  sufficiently 
well  established  by  the  phenomena  of  injections. 

3.  A third  termination  which  is  supposed  to  exist,  but  of  which 
no  sensible  proofs  can  be  given,  is  that  into  colourless  vessels  sup- 
posed to  open  by  minute  orifices  on  various  membranous  surfaces, 
and  therefore  termed  exhalants.  The  nature  of  these  vessels  shall 
he  considered  afterwards. 

Haller  admits  a termination  in,  or  communication  with  lympha- 
tic vessels,  hut  allows  that  it  is  highly  problematical.  Partial  com- 
munications have  been  traced  between  arteries  and  lymphatics  by 
several  anatomists ; but  the  point  requires  to  be  again  submitted 
to  accurate  researches. 


* A Case  of  Obliteration  of  the  Aorta.  By  Joseph  Jordan,  Esq.,  Surgeon  to  the 
Lock  Hospital,  Manchester.  The  North  of  England  Medical  and  Surgical  Journal, 
Vol.  I.  London,  1830-31.  P.  101. 

t Du  Retrecissement  de  1’ Aorta  : Du  Diagnostic  et  du  Traitement  de  cette  Ma- 
ladie,  &c.  Par  le  Docteur  a Le  Grand.  Paris,  1832.  8vo.  Pp.  58. 

$ Case  of  Constriction  of  the  Aorta,  with  Disease  of  its  Valves,  &c.  By  R.  L. 
Nixon,  Surgeon.  Dublin  Medical  Journal,  Vol.  V.  p.  386.  Dublin,  1834. 

§ Instance  of  Obliteration  of  the  Aorta  beyond  the  Arch,  illustrated  by  similar 
Cases  and  Observations.  By  David  Craigie,  M.  D.,  Physician  to  the  Royal  Infirmaiy. 
Edinburgh  Medical  and  Surgical  Journal,  Vol.  LVl.  p.  427. 

II  Eichler  und  Romer  in  Medicinische  lahrbucher  des  Osterreichischen  Staats,  1830. 
B.  XXIX.  N.  2,  S.  200. 

^ Friedrich  Tiedemann,  Von  der  Verengung  und  Schliessung  der  Pulsadern  in 
Krankheiten.  Heidelberg,  und  Leipzig,  1843.  Fall  9. 

3 


AETERY,  .ARTERIAL  TISSUE. 


87 


Another  mode  of  termination,  that,  namely,  into  excreting  ducts, 
admitted  by  Haller,  scarcely  requires  particular  mention.  So  far 
as  an  artery  can  be  said  to  terminate  in  such  a manner,  it  would 
come  under  the  head  of  that  into  exhalant  vessels.  Many  of  the 
proofs  mentioned  by  Haller,  however,  may  he  shown  to  be  exam- 
ples of  a morbid  state  of  the  mucous  membranes  of  these  ducts,  in 
which  their  capillai'y  vessels  are  disorganized. 

In  considering  the  several  terminations  of  arteries,  it  is  not  un- 
important to  advert  to  the  distribution  of  these  vessels.  Injections 
show  that  they  penetrate  into  every  texture  and  organ  of  the  ani- 
mal body,  excepting  one  or  two  substances  in  which  they  have 
never  yet  been  traced.  But  in  different  textures  they  are  found 
in  different  degrees ; and  they  may  vary  in  extent  even  in  the  same 
texture  in  two  different  conditions.  The  parts  which  receive  the 
largest  and  most  numerous  vascular  ramifications  are  the  brain  and 
spinal  chord,  the  glandular  organs,  the  muscles,  voluntary  and  in- 
voluntary, the  mucous  membranes,  and  the  skin.  In  the  fibrous 
membranes,  and  their  modifications,  tendons,  and  ligaments,  and 
in  the  serous  membranes  few  arteries  are  seen  to  penetrate ; and 
these  are  generally  minute,  sometimes  only  colourless  capillaries. 
Bones  hold  in  this  respect  an  intermediate  position,  being  well  sup- 
plied with  blood-vessels,  especially  in  early  life,  though  to  less  ex- 
tent than  the  muscles,  and  in  greater  proportion  than  the  fibrous 
tissues.  In  some  textm-es  arteries  cannot  be  traced,  though  their 
properties  indicate  that  they  must  receive  vessels  of  some  kind. 
Such  are  cartilage  and  the  arachnoid  membrane.  (Ruysch  and 
Haller.)  Lastly,  arteries  are  not  found  in  the  scarf-skin,  in  nails, 
the  enamel  of  the  teeth,  the  hair,  nor  in  the  membranes  of  the  um- 
bilical chord.  In  early  life  bones  are  much  more  vascular  than  in 
adult  age;  and  in  the  bones  of  young  subjects  arteries  maybe 
traced  going  out  through  the  epiphyses  into  the  cartilages,  in  which 
they  cannot  at  a later  period  of  life  be  demonstrated.* 

Section  II. 

The  morbid  states  of  arteries  belong  either  to  the  inner  mem- 
brane, or  to  the  proper  arterial  tissue,  or  to  both. 

1.  Adhesive  Inflammation,  Arteritis.  Acute,  limited.  The 
inner  membrane  is  liable  to  inflammation,  terminating  generally  in 
effusion  of  lymph,  adhesion  of  the  sides,  and  obliteration  of  the 

* Huuter  in  Philosophical  Transactions,  No.  470. 


88 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


canal  of  the  tube.  This  process  takes  place  in  all  circumstances  in 
which  the  corresponding  surfaces  of  the  vessel  are  mutually  applied, 
while  the  current  of  blood  through  the  vessel  is  interrupted.  The 
pressure  of  a tourniquet,  or  any  mechanical  object  moderately  firm ; 
the  pressure  of  a tumour,  or  of  an  aneurism  in  some  instances ; the 
application  of  a ligature  not  so  tight  as  to  divide  the  coats ; and  in 
the  case  of  small  vessels,  the  spontaneous  retraction  and  collapse 
of  its  sides  after  complete  division  by  a cutting  instrument,  are 
conditions  which  have  been  followed  by  adhesion  and  obliteration 
of  the  canal.  On  the  knovdedge  of  this  property  depends  the 
practice  of  tying  arterial  tubes  in  wounds,  and  in  the  cure  of  aneu- 
rism. 

Inflammation  of  the  internal  arterial  membrane  may  also  take 
place  spontaneously,  or  independent  of  mechanical  causes.  Thus 
the  inner  membrane  of  the  aorta  may  be  inflamed  in  persons  labour- 
ing under  general  or  severe  inflammation  of  the  thoracic  viscera. 
(Portal,  Hodgson.)  The  anatomical  characters  are  deep  red  colour 
of  the  membrane,  and  more  or  less  effusion  of  lymph  within  the 
cavity  of  the  vessel. 

If  the  individual  survives  such  a disease,  the  lymph  thus  effused 
becomes  penetrated  with  blood-vessels,  and  forms  a new  body  ad- 
hering to  the  inner  surface  of  the  vessel.  This  is  the  origin  of 
several  of  the  granulated  bodies,  fungous  growths,  or  vegetations, 
which  have  been  described  by  Senac,  Morgagni,  Portal,  Baillie, 
Corvisart,  Burns,  and  Bertin,  as  often  found  at  the  origin  of  the 
aorta,  attached  to  the  semilunar  valves,  or  even  on  the  mitral  valve, 
the  structure  of  which  is  not  dissimilar. 

A red  or  crimson  staining  of  the  inner  membrane,  especially  in 
the  aorta,  has  been  mentioned  by  Corvisart,  Frank,  Hodgson,  and 
Laennec,  and  may  be  often  seen  in  persons  who  have  died  without 
symptoms  of  pectoral  or  arterial  disorder.  Its  nature  is  not  well 
known.  It  seems  to  be  the  effect  of  a dyeing  or  tinging  property 
of  the  blood,  either  during  the  last  moments  of  life,  or  after  the 
heart  has  ceased  to  heat.  It  must  not  be  confounded  with  inflam- 
mation or  its  effects. 

2.  Arteritis  Diffusa.  It  has  been  believed  that  an  extended  or 
diffuse  attack  of  inflammation  might  take  place  over  several  divisions 
of  the  arterial  system  simultaneously  and  successively ; and  the  ex- 
istence of  such  a disease  has  been  maintained  by  Beil,  and  the  two 
Franks.  The  only  unequivocal  facts  in  proof  of  such  a disease, 
however,  have  been  given  by  Tliomson  and  Meli.  In  the  case  oh- 


ARTERY,  ARTERIAL  TISSUE. 


89 


served  by  the  former,  the  inflammatory  attack  which  appeared  suc- 
cessively in  the  femoral  and  humeral  arteries  appears  to  have  been 
the  consequence  of  previous  chronic  inflammation  of  these  vessels ; 
and  consequently  the  case  is  not  a pure  example  of  idiopathic  acute 
arteritis.  In  the  case  given  by  Meli,  there  is  no  reason  to  believe 
that  the  acute  attack  was  preceded  by  chronic  disease  of  the  arteries  ; 
and  that  probably  is  the  least  objectionable  example  of  the  disease. 
The  symptoms  during  life  were  pain  along  the  course  of  the  large 
vessels ; violent  throbbing  and  beating  in  all  the  arteries  of  the  ex- 
tremities which  were  felt  like  tense  chords ; much  heat ; great  and 
intense  fever,  thirst,  restlessness ; and  finally  delirium  and  death. 
The  arteries  were  found  covered  with  lymph  outside,  thickened, 
and  containing  internally  clots  of  blood  and  lymph  ; and  the  tunics 
were  roughened.* 

Inflammation  less  extensive  but  not  less  intense  takes  place  in 
arteries  about  to  be,  or  already  affected  wdth  aneurism.  In  almost 
all  cases  of  aneurism  the  arterial  tunics  are  previously  in  a state  of 
inflammation.  The  tunics  are  reddened  and  softened,  though  la- 
cerable ; sometimes  ulceration  takes  place  in  various  points ; clots 
of  blood  and  lymph  are  deposited  ; and  pain  is  felt  in  the  site  and 
along  the  course  of  the  artery.  When  aneurismal  enlargement 
has  actually  taken  place,  it  is  attended  with  manifest  tokens  of  the 
presence  of  inflammation.  Pain,  generally  severe  and  lasting,  is 
felt  along  the  course  of  the  vessel  and  on  the  seat  of  the  aneurismal 
dilatation.  In  cases  of  aneurism  of  the  aorta  or  innominata,  pain 
is  felt  proceeding  upwards  to  the  neck  and  head  on  the  left  side ; 
and  though  much  of  this  is  caused  by  pressure  of  the  tumour  on 
nerves,  yet  much  also  is  caused  by  inflammation  in  the  aneurismal 
tumour,  and  in  the  vessel  or  vessels  proceeding  from.  They  are 
found  red,  softened,  thickened,  lined  with  lymph  and  clots  of  blood, 
and  presenting  points  of  ulceration  and  steatomatous  and  osseous 
deposit,  the  efiects  of  the  chronic  inflammation. 

3.  Chrordc  Inflammation.  In  persons  who  have  long  laboured 
under  the  constitutional  effects  of  the  syphilitic  poison,  or  who  have 
been  repeatedly  and  permanently  under  the  influence  of  mercury, 
especially  in  cold  and  variable  climates,  the  arterial  tissue  is  not 
unfrequently  affected  by  a slow  insidious  process  of  inflammation. 
It  is  not  easy  to  determine  to  what  extent  this  may  affect  the  inner 
membrane  exclusively ; for  probably  both  suffer  at  the  same  time, 
and  from  the  same  causes : but  the  effects  of  the  process  differ  in 

* On  Acute  Aortitis.  By  Norman  Chevers,  M.  D.  Guy’s  Hospital  Reports,  VoL 
VI.  p.  304. 


90 


GENERiVL  AND  PATHOLOGICAL  ANATOMY. 


tlie  two  tissues.  In  the  inner  membrane  chronic  inflammation  may 
cause  partial  effusion  of  lymph,  which  becoming  organized  gives 
rise,  as  already  mentioned,  to  the  production  of  fungous  growths 
and  vegetations.  It  may  render  the  membrane  opaque  and  thick, 
and  give  it  a shrivelled  puckered  appearance.  It  may  cause  a tu- 
bercular thickening  either  of  the  membrane  or  of  the  semilunar 
valves.  It  may  induce  gristly  induration  especially  in  these  and  in 
the  mitral  valve.  Or,  lastly,  there  is  reason  to  believe  it  is  often 
the  agent  of  the  processes  next  to  be  considered, — calcareous  de- 
position, steatomatous  deposition,  and  atheromatous  deposition. 

When  it  causes  tubercular  thickening,  the  inner  surface  of  the 
aoi’ta  from  the  semilunar  valves  upwards  along  the  whole  course 
of  the  arch  is  covered  with  small  irregular-shaped  orbicular  emi- 
nences, placed  at  irregular  intervals  along  the  course  of  the  cylinder 
of  the  artery.  From  this  they  extend  into  the  innominata,  the  left 
carotid  and  left  subclavian,  and  often  they  are  found  beyond  the 
arch  at  the  origin  of  the  intercostal  arteries. 

These  bodies,  for  which  their  shape  and  appearance  has  procured 
the  name  of  tubercles  and  warts,  I think  are  merely  lymph  of  a 
particular  kind  deposited  either  by  the  inner  coat,  or,  as  sometimes 
seems  to  be  the  case,  by  the  middle  coat,  in  a state  of  chronic  in- 
flammation, and  assuming  the  tubercular  or  verrucose  shape,  ap- 
pearance, and  disposition. 

The  opinion  that  cartilaginous  and  osseous  induration  of  the  se- 
milunar and  mitral  valves  depends  on  chronic  inflammation,  derives 
great  probability  from  several  circumstances  observed  in  the  origin 
and  progress  of  these  changes.  In  the  first  place,  in  the  serous 
membranes  the  formation  of  cartilaginous  and  osseous  patches  is 
often  preceded  by  distinct  marks  of  inflammation.  Though  we 
cannot  prove  absolute  identity  between  these  textures  and  the  inner 
cardiac  and  arterial  membrane,  yet,  as  in  many  of  their  properties 
they  are  very  similar,  there  is  reason  to  believe  that  in  this  also 
they  resemble  each  other.  In  the  second  place,  after  or  along 
with  rheumatic  attacks,  it  is  not  uncommon  to  observe  symptoms  of 
a morbid  state  in  one  or  both  sets  of  valves  ; symptoms  of  rigidity 
and  immobility  ; and  symptoms  of  more  or  less  contraction  of  the 
orifices  which  they  form.  Thirdly,  the  presence  of  more  or  less 
disease  in  the  semilunar  aortic  valves  is  usually  associated  with  in- 
dications of  the  effects  of  chronic  inflammation  of  the  aortic  lining 
membrane ; roughness  of  its  interior  caused  by  tubercular,  steato- 
matous, or  atheromatous  growths. 


ARTERY,  ARTERIAL  TISSUE. 


91 


It  is  doubtless  true  that  these  chauges  in  the  valves  may  be  re- 
garded as  eflFects  and  examples  of  misnutrition,  {paratrophiaJ) 
This,  however,  would  not  alter  much  the  essential  merits  of  the 
question  ; for  most  instances  of  misnutrition  are  accompanied  with 
marks  of  chronic  inflammation,  and  one  of  the  leading  characters 
of  chronic  inflammation  may  be  said  to  be  the  derangement  in 
the  nutrition  of  the  parts  which  it  attacks.  It  must  be  allowed  also 
that  often  the  changes  take  place  insidiously  and  in  an  impercep- 
tible manner.  The  most  decided  evidence,  however,  as  to  the 
cause  of  these  changes  being  inflammation  or  not  is  found  in  the 
examination  of  the  changes  themselves. 

In  the  semilunar  aortic  valves  they  are  as  follow. 

1.  The  valves  may  be  mutually  adherent  by  their  edges;  that  is, 
two  valves  may  adhere ; or  the  whole  three  may  be  mutually  adhe- 
rent. In  other  instances  two  valves  only  may  adhere ; and  the 
coalescence  may  be  so  perfect  that  there  shall  appear  to  be  only 
two  semilunar  valves  instead  of  three.  When  all  the  three  adhere 
they  produce  very  great  occlusion  of  the  orifice  of  the  aorta.  In 
one  case  which  I knew  well,  the  aperture  scarcely  admitted  a silver 
catheter  of  calibre  No.  10. 

2.  The  semilunar  valves  may  be,  without  mutual  accretion,  ri- 
gid, firm,  and  immovable,  or  at  least  not  readily  movable.  This 
state  is  manifestly  caused  partly  by  deposition  on  their  upper  and 
under  surface,  partly  by  thickening  of  their  substance.  In  general 
this  deposit  and  thickening  is  greatest  at  the  attached  margin  of 
the  valves.  They  are  at  the  same  time  shrivelled  or  drawn  irre- 
gularly fi’om  the  free  margin  to  the  attached.  In  this  state  the 
blood  regurgitates  from  the  aorta  into  the  left  ventricle. 

3.  The  whole  surface  and  margins  of  the  valves  may  be  covered 
by  small  tubercular  bodies,  varying  in  size,  like  pin-heads,  or  split 
vetches,  and  sometimes  irregular  on  the  apices  like  warts.  The 
valves  are  thickened  and  rendered  rigid  and  shrivelled.  If  these 
be  not  the  effects  of  chronic  inflammation,  they  are  products  of  mis- 
nutrition. They  are  deposited  at  first  as  lymph. 

4.  I have  seen  the  following  state  of  the  semilunar  valves.  The 
whole  three  valves  were  thickened,  stiffened,  and  indurated ; and 
their  surfaces  were  covered  with  a series  or  crop  of  hair -like  or 
bristly  processes,  growing  from  tbe  attached  margin  and  both  sur- 
faces of  the  valves,  and  projecting  into  the  area  of  the  artery,  not 
unlike  a hair-like  fringe.  It  seems  difficult  to  understand  the  for- 


92 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


mation  of  these  bodies  unless  they  were  from  chronic  inflammation 
affecting  the  valves.  The  person  in  whom  they  were  observed  died 
within  three  hours  after  his  admission  to  the  hospital.  He  was  a 
stout  agricultural  labourer,  about  47  or  50  years  of  age.  But  of 
his  previous  state  his  friends  gave  no  information,  except  that  he 
had  been  attacked  with  difficult  breathing  and  uneasiness  in  the 
chest  about  ten  days  before  he  applied  for  assistance.  His  pulse 
was  feeble  and  the  surface  cold  when  he  was  admitted. 

5.  The  surface  or  margins  of  the  valves  may  present  globular 
or  spheroidal  softish  dark-red  coloured  bodies  like  the  granules  of 
cauliflower  adhering  to  them.  These  are  aggregated  in  masses,  so 
as  to  form  something  like  fungous  or  cauliflower  growths.  They 
are  friable  and  easily  broken  off,  and  most  commonly  in  handling 
them,  many  are  removed.  These  bodies  seem  to  be  originally 
masses  either  of  lymph  or  fibrin,  which  thus  are  either  effused  by, 
or  adhere  to  the  valves  in  a state  of  inflammation. 

4.  Ossification,  Earthy  Degeneration  of  Scarpa  ; Calcareous  De- 
position. It  has  been  long  known  that  arteries  are  liable  to  depo- 
sition of  calcareous  matter.  By  De  La  Sone  it  was  first  remarked 
that  this  process  takes  place  in  the  inner  membrane  only;*  and 
Bichat  afterwards  referred  it  to  the  outer  or  attached  surface  of 
the  membrane,  an  opinion  in  which  he  is  supported  by  the  testi- 
mony of  Meckel,  Scarpa,  Hodgson,  and  others.  Scarpa  only  ad- 
mits as  a possible  alternative  its  deposition  in  the  interval  between 
the  inner  and  proper  coat  in  the  delicate  tissue  termed  second  cellu- 
lar by  Haller.f  By  Jourdan  and  Breschet,  however,  the  transla- 
tors of  the  work  of  Meckel,  who  contend  that  the  internal  mem- 
brane is  never  ossified,  it  is  positively  stated  that  the  calcareous 
matter  is  accumulated  in  the  cellular  tissue  connecting  the  inner 
to  the  proper  coat.  It  is  perhaps  of  no  great  moment  to  dispute 
this  point ; but  I shall  mention  three  facts,  which  show  that  the 
statement  of  MM.  Jourdan  and  Breschet  must  be  admitted  with 
caution.  1st,  There  is  no  cellular  tissue  between  the  two  mem- 
branes,^  and  the  inner  adheres  simply  to  the  proper  coat.  This 
is  established,  notwithstanding  the  authority  of  Haller,  by  dissec- 
tion, and  by  observing  the  effects  of  maceration  and  boiling. 
Calcareous  deposition  is  observed  to  take  place  at  the  semilunar 

* Memoires  de  I’Academie  Royale,  1756,  p.  199,  12mo. 

.f*  Suir  Aneurisma,  Capitolo  v.  § 29. 

“ La  surface  externe,  foiblement  unie  a I’autre  membrane,  comme  nous  I’avons 
vu,  n’a  point  un  intermediare  cellulaire.” — Bichat,  Tome  I.  p.  291. 


AETERY,  ARTERIAL  TISSUE. 


93 


valves,  which  consist  of  two  folds  of  inner  membrane,  when  it  is 
found  in  no  other  part  of  the  aorta.  Mly,  Admitting,  for  the  sake 
of  argument,  that  cellular  tissue  is  placed  between  the  inner  coat 
and  the  proper  arterial  tissue,  if  calcareous  matter  be  deposited  in 
it,  it  is  not  analogous  to  what  is  observed  in  this  tissue  elsewhere. 
Without  relying  much,  however,  on  these  facts,  I shall  state  the 
ordinary  mode  in  which  the  deposition  appears,  independent  of  any 
opinion  as  to  its  precise  source. 

The  calcareous  incrustation  commences  invariably  at  the  outer 
surface  of  the  inner  membrane  in  the  form  of  minute  gritty  points, 
or  of  small  isolated  patches.  In  the  former  state  they  appear  to 
be  hard  and  crystalline,  and  render  the  inside  of  the  vessel  rough  ; 
in  the  latter  they  are  simply  firm,  and  are  less  earthy  or  gritty,  and 
without  forming  asperities  in  the  inside  of  the  vessel,  may  make  it 
merely  firm  and  unyielding,  and  deprive  it  of  its  elasticity.  In 
either  case,  these  calcareous  deposits,  confined  more  or  less  to  one 
side,  may  spread  along  the  tube  for  a considerable  extent.  They 
seldom  affect  the  whole  circumference  of  an  artery  unless  in  the 
lower  extremities,  in  which  they  have  been  observed  to  form  dis- 
tinct rings,  connected  by  intermediate  portions  of  sound  artery. 
(Hodgson.) 

When  the  deposition  is  partial  and  limited,  and  of  short  duration, 
it  is  still  covered  by  the  inner  membrane ; and  the  inside  of  the 
vessel,  though  irregular,  is  comparatively  smooth.  When  the 
patches  multiply  and  enlarge  so  as  to  coalesce,  the  inner  membrane 
gives  way  at  one  or  more  points  of  the  margin  of  the  calcareous 
deposite,  which  now  adheres  only  to  the  surface  of  the  proper  mem- 
brane ; and  an  irregular  ragged  circumference  is  exposed.  If  the 
artery  contains  many  patches,  its  entire  inner  surface  presents  a 
series  of  asperities  resulting  from  the  rupture  of  the  thin  pellicle  of 
inner  membrane  with  which  they  were  at  first  covered.  Yet  these 
calcareous  patches  are  not  known  to  be  detached  entirely. 

Scarpa  represents  this  morbid  change  as  taking  place  something 
difierently.  But  1 shall  afterwards  show  that  this  arises  from  con- 
founding the  calcareous  with  the  steatomatous  deposition,  a change 
different  in  several  respects. 

In  many  instances  of  aged  persons,  the  calcareous  deposit  ap- 
pears in  the  form  of  rings  of  bony  matter,  into  which  the  circular 
fibres  of  the  middle  coat  are  transformed.  It  often  happens  that 
the  arteries  of  the  extremities  are  thus  converted  into  bony  tubes. 

This  deposition  may  take  place  in  any  part  of  the  arterial  sys- 


94 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


tem  ; and  it  is  said  to  be  equally  common  in  branches  as  in  trunks. 
It  may  occur  in  the  radial  artery,  in  the  temporal,  or  in  the  tibial. 
By  Cowper  and  Naish  it  was  found  in  the  arteries  of  the  leg  in 
the  course  of  amputation.*  I have  seen  it  in  the  radial  and  ulnar 
in  tying  the  vessels  of  an  amputated  fore- arm ; and  in  the  femoral 
and  several  of  the  perforating  branches  of  the  thigh  under  the  same 
circumstances.  It  is,  however,  most  commonly  found  in  the  arch  of 
the  aorta,  or  in  some  of  the  branches  which  issue  from  it.  Many 
cases  of  its  occurrence  in  the  coronary  arteries  have  been  recorded. 
(Crell,  Erdmann,  Frank,  and  Parry.)  Nor  is  it  confined  to  the  arterial 
tubes  only ; for  it  is  seen  in  that  part  of  the  pellucid  arterial  membrane 
which  forms  the  valves,  and  lines  the  inside  of  the  left  ventricle,  and 
is  frequently  found  to  take  place  in  the  semilunar  and  mitral  valves. 

The  nature  of  this  deposition  has  given  rise  to  various  specula- 
tions. But  this  variance  has  partly  arisen  from  the  practice  of 
confounding  it  with  the  steatomatous  deposition.  It  is  said  to  dif- 
fer from  osseous  matter  in  two  circumstances.  First,  The  deposi- 
tion is  earthy  from  the  first,  without  any  previous  matrix  of  animal 
matter.  Secondly,  It  is  destitute  of  the  usual  fibrous  structure, 
and  presents  an  irregular  but  homogeneous  crust  without  any  ob- 
vious arrangement.  It  consists,  however,  of  the  usual  combina- 
tion of  animal  matter  and  bone  earth.  A specimen  analyzed  by 
Mr  Brande  gave  65’5  parts  of  phosphate  of  lime,  and  34‘5  of  ani- 
mal matter  in  the  100  parts.  The  latter  was  chiefly  albumen,  with 
traces  of  gelatine. 

Calcareous  deposition  may  take  place  at  any  period  of  life,  but 
is  supposed  to  be  most  common  in  advanced  age.  Portal,  Scarpa, 
and  Hodgson,  mention  instances  of  its  occurrence  in  young  sub- 
jects. According  to  Stevens,  it  is  more  common  to  find  the  arte- 
ries ossified  than  healthy  after  the  30th  year.f  But  this  statement 
is  probably  delivered  in  too  general  terms,  and  from  too  limited  a 
collection  of  cases,  Baillie  restricts  its  occurrence  as  a general 
pbenomenon  to  the  period  after  the  60th  year  and  this  corre- 
sponds with  the  inference  of  Bichat,  who  states,  that  in  ten  subjects 
seven  at  least  present  these  incrustations  after  the  60th  year.§  Its 
influence  on  the  circulation  varies  at  different  periods  of  life,  and 
according  to  its  extent  and  situation.  In  the  aged  it  is  said  to 

* Philosophical  Transactions,  No.  285,  p.  1391,  and  No.  369,  p.  226. 

t Medico-Chirurgical  Transactions,  Vol.  V.  p.  433. 

t Transactions  of  a Society  for  the  Improvement,  &c.,  Vol.  I.  jr.  133. 

§ Anatomic  Generale,  Vol.  II.  p.  292. 


ARTERY,  ARTERIAL  TISSUE. 


95 


produce  much  less  inconvenience  than  in  the  young  and  adult. 
(Bichat.)  It  is  certain  that  in  the  latter  it  almost  invariably  causes 
fatal  disease  of  the  heart  or  arteries,  or  of  both. 

The  most  ordinary  effect  of  calcareous  incrustation,  when  exten- 
sive, is  to  induce  chronic  inflammation  and  ulceration  of  the  arterial 
tissue.  The  earthy  matter  operates  as  a foreign  body,  and  by  con- 
stant irritation  destroys  the  vitality  of  the  inner  membrane,  which 
exfoliates,  and  inflames  the  proper  tissue,  which  is  then  eroded.  In 
this  state  the  occasional  application  of  a slight  force  may  be  followed 
by  more  or  less  laceration  of  the  proper  coat.  In  arteries  covered 
by  a filamentous  sheath,  the  blood  thus  discharged  is  injected  into 
the  sheath,  which  is  then  distended  into  a spherical  sac  situate  more 
or  less  on  one  side  of  the  vessel.  This  forms  the  disease  described 
as  true  aneurism  by  Scarpa.  In  arteries  not  supplied  with  fila- 
mentous sheath,  as  in  the  brain,  the  blood  escapes  freely,  and  may 
by  its  quantity  induce  fatal  compression  of  that  organ.  (Blane, 
Hodgson,  Bouillaud,  and  Serres.) 

The  calcareous  deposition  renders  the  arterial  tube  so  brittle, 
that  the  application  of  a ligature  invariably  cracks  it,  prevents  the 
usual  process  of  adhesion,  and  is  generally  succeeded  by  ulceration 
and  hemorrhage.  In  persons  advanced  in  life  calcareous  deposi- 
tion in  the  arteries  of  the  lower  extremities  is  a cause  not  unfre- 
quent of  mortification  of  the  toes,  feet,  and  legs,  generally  termi- 
nating fatally.  (Cowper,  Naish,  and  Pott.) 

5.  Atheromatous  Deposition.  This  term  has  been  applied  to  a 
semifluid  or  cheesy  opaque  substance,  which  is  not  unfrequently 
found  hetw'een  the  inner  and  proper  tunics  of  arteries.  Its  consis- 
tence may  vary  from  that  of  purulent  matter  to  the  tenacity  of 
curd,  or  the  granular  firmness  of  cheese.  Observed  by  the  first 
Monro,  by  Haller,  and  others,  it  appears  to  he  considered  by  Scarpa 
as  a variety  of  the  same  change  which  I am  afterwards  to  mention 
as  steatomatous  deposition.  From  this  certain  circumstances  show 
that  it  ought  to  be  distinguished.  Is?,  Atheromatous  deposition 
appears  to  arise  from  a sort  of  suppuration;  for,  in  genei’al,  it  is 
possible  to  trace  the  transition  from  purulent  fluid  to  the  concrete 
matter  of  atheroma.  2cf,  This  account  of  its  origin  derives  strong 
confirmation  from  the  fact,  that  it  almost  always  contains  a patch 
or  patches  of  calcareous  matter  in  its  centre.  Mly,  It  is  associated 
much  more  frequently  with  the  calcareous  than  with  the  steatoma- 
tous deposite.  It  is  for  these  reasons  not  unlikely  that  the  athero- 


96 


GENERAL  AND  PATHOLOGICAL  ANATOMY, 


matous  deposition  is  to  be  viewed  as  one  of  the  effects  of  chronic 
inflammation,  either  in  the  inner  or  the  proper  tunic,  or  in  both. 

6.  Steatomatous  Deposition^  either  alone,  or  with  calcareous  patch- 
es, is  often  found  between  the  inner  surface  of  the  proper  membrane, 
and  the  outer  surface  of  the  internal  one.  Whether  these  depo- 
sits invariably  derive  their  origin  from  the  former  or  from  the  lat- 
ter of  these  tissues,  is  not  easy  to  say.  In  many  instances  they  ap- 
pear to  be  produced  rather  by  the  proper  arterial  tunic.  They 
occur  in  various  forms ; but  two  may  be  particularly  mentioned. 

In  the  first,  small  irregular  patches  of  yellowish  or  fawn-coloured 
matter  like  wax  appear  on  the  inner  surface  of  the  proper  coat.  As 
the  process  of  deposition  advances,  these  become  thicker  and  broad- 
er. They  coalesce,  and  sensibly  raise  the  outer  filamentous  coat; 
while,  by  their  prominence  interiorly,  they  diminish  the  capacity  of 
the  arterial  tube.  At  the  same  time  the  inner  membrane  becomes 
irregular,  opaque,  and  shrivelled ; and  the  connection  with  the  pro- 
per tunic  being  destroyed,  it  is  detached  with  great  facility.* 

This  deposition  constitutes  the  steatomatous  degeneration  of  Pro- 
fessor Scarpa  and  other  authors.  The  name  is  not  well  chosen, 
for  the  substance  dejjosited  is  not  adipose,  but  rather  like  crude 
bees-wax.  It  was  applied,  however,  by  Stentzel,|  the  original  wri- 
ter on  this  subject,  and  it  is  unnecessary  to  change  it,  when  its  ex- 
act import  is  understood.  Though  it  may  occur  probably  in  any 
part  of  the  arterial  tubes,  it  takes  place  most  frequently  at  the  bi- 
furcations of  the  arteries.  It  invariably  commences  in  this  parti- 
cular spot  of  the  vessel ; and  when  it  occupies  any  extent  of  the 
tube,  it  will  be  found  to  have  begun  at  the  bifurcation,  and  spread 
thence  along  the  vessel.  Thus  I have  seen  this  deposition  confined 
to  the  point  common  to  the  common  carotid,  and  its  external  and 
internal  branches,  and  this  in  both  sides  in  the  same  subject.  I 
have  seen  it  in  another  person  at  the  same  part  of  the  carotids,  and 
at  the  point  common  to  the  internal  carotid  and  the  sylvian  artery. 
Lastly,  in  another  instance  I have  found  it  affecting  at  once  in  the 
same  subject  the  arch  of  the  aorta,  where  it  gives  off  the  innorninata 
and  left  subclavian  artery ; the  descending  aorta,  where  it  gives  off 
the  coeliac  and  superior  mesenteric,  including  the  beginning  of  these 
vessels  ; and  the  coeliac,  when  it  divides  into  its  gastric,  hepatic, 
and  splenic  branches. 

* Morgagni  Epist.  XXIII.  Ai-t.  iv.  vi.  XLV.  Art.  xxiii.  &c. 

+ Christiani  God.  Stentzel  de  Steatomatibus  Aortee.  Haller  Disput.  ad  Morborum 
Historiam,  &c.  Tomo  II.  p.  527.  Art.  Lxv. 


ARTERY,  ARTERIAL  TISSUE. 


97 


In  describing  this  morbid  state  of  arteries,  Professor  Scarpa,  T 
conceive,  confounds  it  with  ossification.  After  noticing  the  loss  of 
fine  polish  (Tintima  tonaca  delV  arteria  perde  per  certo  tratto  siio  bel 
liscio,)  which  the  inner  arterial  membrane  sustains,  he  represents  it 
as  becoming  irregular  and  wrinkled,  and  successively  occupied 
with  yellow  spots,  which  are  converted  into  so  many  earthy  grains 
or  scales,  or  into  steatomatous  and  caseous  concretions.  I think 
they  may  be  justly  distinguished,  because  the  calcareous  deposite 
very  often  exists  without  the  steatomatous;  and  conversely,  the 
steatomatous  may  be  found  without  the  calcareous  deposition.  I 
must  not  omit  to  mention,  nevertheless,  that  the  circumstance  which 
seems  to  have  led  Scarpa  to  consider  these  depositions  as  the  same, 
is,  that  sometimes  in  the  centre  of  a steatomatous  patch  is  found  a 
broad  scale  of  hard  substance,  not  so  firm  as  bone,  and  not  so  crys- 
talline or  gritty  as  the  genuine  calcareous  deposition.  It  is  gene- 
rally so  soft  as  to  be  flexible,  and  resembles  rather  a firm  piece  of 
cartilage  than  true  bone.  It  may  be  designated  as  the  steatomatous 
and  osteo-steatomatous  deposition. 

Scarpa  represents  the  steatomatous  state  as  proceeding  invaria- 
bly to  ulceration.  This,  however,  is  not  a uniform  result.  A large 
portion  of  an  artery  may  be  affected  with  it  without  suffering  the 
smallest  breach  of  continuity  or  destruction  of  tissue.  It  simply 
distends  the  vessel  mechanically ; and  if  unaccompanied  with  cal- 
careous deposition,  this  distension  may  be  considerable  without  any 
ulceration  or  laceration.  In  this  manner  probably  are  produced 
those  simple  dilatations  of  arteries  which  by  many  of  the  French 
authors  are  regarded  as  aneurism.  In  other  instances,  more  espe- 
cially when  the  steatomatous  is  combined  with  the  calcareous  de- 
position, or  when  the  arterial  tunics  have  been  long  and  much  dis- 
tended, ulceration  may  take  place  and  terminate  in  partial  or  en- 
tire destruction  and  rupture  of  the  arterial  tunics.  In  genei’al, 
this  destruction  takes  place  in  the  transverse  direction,  (Hodgson,) 
and  the  laceration  or  fissure  is  therefore  across  the  tube. 

In  such  circumstances,  if  the  aperture  is  not  large  enough  to 
cause  fatal  hemorrhage,  aneurism  first  by  dilatation,  and  ultimately 
by  rupture,  is  the  consequence. 

Of  all  these  changes  or  deposits,  tubercular,  atheromatous,  steato- 
matous, or  calcareous,  the  invariable  effect  is  to  render  the  arterial 
tunics  brittle,  to  impair  their  elasticity  and  contractile  power,  and  to 
render  them  less  pliant  and  more  easily  ruptured.  Hence  in  arteries 

G 


98 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


diseased  in  these  modes,  as  the  tunics  do  not  easily  become  distended, 
they  are  liable  to  give  way  and  burst  on  any  occasion  when  the  blood 
is  either  accumulated  or  delayed  within  their  canals,  or  when  the 
vessels  themselves  are  exposed  to  any  extraordinary  stretching  or 
twisting  motion.  Sudden  or  violent  motion  of  any  kind,  indeed, 
is  liable  to  produce  rupture  of  arteries  diseased  and  rendered 
brittle  in  the  manner  now  specified. 

In  short,  arteries  in  this  state  are  liable  to  inflammation,  ulcera- 
tion, and  rupture. 

7.  Aneurism.  On  the  nature  of  the  aneurismal  tumour  some 
difference  of  opinion  has  prevailed.  Since  it  has  been  the  custom 
to  settle  points  of  pathology  by  reference  to  dissection,  three  opi- 
nions have  been  successively  entertained.  First.^  It  w’as  maintain- 
ed by  Elsnei’,  Severinus,  Hildanus,  Sennert,  and  others,  that 
aneurism  was  produced  by  rupture  of  the  proper  coats  of  the  ar- 
tery. The  second  opinion,  which  is  that  of  Fernel,  Forestus, 
Diemerbroek,  &c.  is,  that  it  consists  in  uniform  dilatation  of  the 
arterial  tunics.  Thirdly,  From  the  cases  recorded  by  I^ancisi, 
Friend,  Guattani,  Morgagni,  and  especially  those  described  by 
Donald  Monro,*  it  results  that  aneurism  may  arise  either  from 
rupture  or  from  dilatation  of  the  arterial  tissues,  or  from  both  causes 
jointly. 

The  first  doctrine  has  been  revived  and  strenuously  and  ingeni- 
ously defended  by  Scarpa,  who  infers  that  aneurism  never  consists 
in  dilatation,  but  invariably  arises  from  erosion  and  laceration  of 
the  proper  coats,  and  injection  of  arterial  blood  into  the  filamentous 
or  membranous  sheath  with  which  the  vessel  is  invested.  By  Hodg- 
son, again,  this  docti’ine  has  been  successfully  combated,  and  the 
third  opinion  shown  to  be  most  consonant  with  the  process  of  aneuris- 
mal disease.  The  result  of  his  inquiries  may  be  stated  in  the  follow- 
ing manner.  In  many  aneurisms  the  first  step  is  destruction 

and  partial  laceration  of  the  internal  and  proper  coats  of  the  artery  ; 
and  when  the  blood  escapes  from  its  cavity  it  distends  the  filamen- 
tous or  membranous  sheath  into  a cyst  or  sac,  between  which  and 
the  tunics  it  is  found  in  successive  layers.  2c?Zy,  In  several  aneu- 
risms the  first  step  of  the  process  is  mere  dilatation  of  the  arterial 
tunics,  either  partial  or  general.  When  this  has  proceeded  to  a 
certain  extent,  varying  in  different  cases,  the  arterial  tissues  give 
way,  and  the  same  process  of  hemorrhage  and  coagulation  in  suc- 
cessive layers  results. 

* Essays  and  Observations,  Phys.  and  Lit,  Vol.  III.  Art.  xii. 


ARTERY,  ARTERIAL  TISSUE. 


99 


It  appears,  therefore,  that  in  every  case  of  aneurism  there  is 
eventually  laceration.  The  only  difference  is  in  the  mode  of  ori- 
gin, which  in  some  is  rupture,  and  in  others  mere  dilatation.*  This 
question  M.  Breschet  investigated  anatomico-pathologically in  1832, 
and  drew  the  following  conclusions.  1st,  That  there  exist  true 
aneurisms,  that  is,  aneurisms  consisting  in  dilatation  of  the  ar- 
terial walls  without  any  apparent  lesion,  and  without  any  solution 
of  continuity  in  the  membranes  of  these  vessels.  2d,  That  arteries 
of  all  calibres,  from  the  largest  to  the  most  capillary,  may  undergo 
this  dilatation.  ?>d,  That  the  arteries  of  bone  are  liable  to  this  expan- 
sion. ‘^th.  That  these  true  dilatations  may  be  distinguished  as  to  ex- 
ternal form,  into  a.  sacciform,  b.  fusiform,  or  spindle-shaped,  c. 
cylindroid,  and  d.  cirsoid,  or  arterial  varix ; that  there  are  also 
mixed  aneurisms  in  which  the  middle  arterial  tunic  is  torn,  and 
in  which  the  inner  is  proti’uded  through  it  in  the  form  of  a hernial 
tumour,  while  the  external  or  cellular  coat  is  dilated  and  forms  the 
exterior  covering  of  the  aneurism ; and  that  this  mixed  aneurism 
depends  on  lesion  of  the  arterial  tunics,  and  may  be  multiplied,  that 
is,  more  than  one  occurring  in  the  same  individual.f 

This  accords  generally  with  the  results  obtained  by  Mr  Hodg- 
son. But  it  must  be  observed,  that,  whatever  be  the  amount  of  ex- 
perience in  France  as  to  the  comparative  frequency  of  trire  aneu- 
rism and  mixed  aneurism,  it  is  certain  that  the  latter  is  the  form  of 
disease  most  common  in  England.  It  may  be  said  that  we  see  fifty 
cases  of  mixed  aneurism  for  one  of  true  aneurism.  In  short,  aneu- 
rism in  England  is  a disease  dependent  on  previous  lesion  of  the 
arterial  tunics. 

In  its  final  result  an  aneurismal  sac  bursts  in  one  of  two  modes. 
l.s^,  When  it  bursts  into  the  cavity  of  any  of  the  serous  membranes, 
as  the  pleura,  pericardium,  or  peritonaeum,  the  breach  is  formed  by 
laceration.  2d,  When  it  bursts  through  the  skin  or  into  cavities 
lined  by  a mucous  membrane,  the  breach  is  the  effect  of  sloughing 
and  ulceration. 

Certain  divisions  of  the  arterial  system  are  evidently  more  liable 
than  others  to  aneurism  ; and  in  general  the  comparative  liability 
may  be  traced  to  the  greater  or  less  susceptibility  of  disease  of  the 
tunics,  and  the  situation  of  the  vessel  in  being  exposed  to  frequent 
motion.  Hence  aneurisms  are  calms  paribus  more  frequently 

* Hodgson  on  the  Diseases  of  Arteries  and  Veins,  p.  74. 

f Memoire  sur  les  Aneurismes.  Par  M.  Gilbert  Breschet.  Memoires  de  I’Aca- 
demie  Royale  de  Medecine,  Tome  troisieme.  Paris,  1833.  4to,  p.  101. 


100 


GENERAL  AND  PATHOLOGICAL  ANATOBIY. 


observed  at  the  flexures  of  joints  than  elsewhere.  Aneurisms  are 
also  more  frequent  in  men  than  in  women.  The  following  table 
by  Mr  Hodgson  exhibits  the  comparative  frequency  of  true  aneu- 
risms in  different  arteries,  and  in  the  two  sexes,  in  sixty-three  cases 
in  which  that  gentleman  either  saw  the  patients  during  life,  or  ex- 


amined  the  parts  after  death. 

Males. 

Females. 

Total. 

Of  the  ascending  aorta,  the  arteria  innominata,  and  the 

arch  of  the  aorta, 

16 

.5 

21 

descending  aorta. 

7 

1 

8 

carotid  artery  .... 

2 

2 

subclavian  and  axillary  arteries. 

5 

5 

inguinal  artery,  .... 

12 

12 

femoral  and  popliteal  artery,  . 

14 

1 

15 

66 

7 

63 

Aneurism  in  this  country  is  most  commonly  seen  in  the  arch  of 
the  aorta  or  innominata,  or  both.  In  the  course  of  eight  years  1 
have  observed  nine  cases,  and  dissected  eight  of  these.  Only  one 
was  in  the  abdominal  aorta, 

8.  Cirsoid  Aneurism  of  M.  Breschet.  Aneurysma  Cirsus.  An- 
eurysma  Cirsoideum.  Varix  Arterialis  of  M.  Dupuytren.  Arterial 
Varix. 

The  name  Cirsoid  Aneurism  is  applied  by  Breschet  to  a tumour 
of  an  arterial  tube  or  tubes,  called  by  Dupuytren  Arterial  Varix, 
because  arteries  affected  by  it  may  be  compared  to  varicose  veins. 
It  consists  in  dilatation  of  the  vessel  in  a greater  or  less  extent  of  its 
course,  often  through  the  whole  length  of  the  trunk  and  its  princi- 
pal branches.  The  vessel  at  the  same  time  becomes  elongated  and 
tortuous,  and  describes  circuits  more  or  less  numerous  and  consi- 
derable. Sometimes,  besides  these  sudden  dilatations  of  the  tube,  in 
some  parts  are  seen  nodosities  or  little  circumscribed  aneurismal  tu- 
mours, which  are  true  sacciform  aneurisms,  and  occasionally  mixed 
aneurisms. 

Most  frequently  the  parietes  of  the  vessel  are  thin,  soft,  and  flaccid ; 
and  when  divided,  they  collapse  like  those  of  varicose  veins ; while  in 
true  cylindroid  aneurism  the  parietes  are  thickened ; and  if  divided 
perpendicularly  to  their  axis,  the  diameter  (calibre)  of  the  vessel  re- 
mains open.  The  artery  affected  with  varix  resembles  much  a varicose 
vein,  and  for  such  it  might  easily  be  mistaken  if  injection  or  dissec- 
tion to  the  principal  trunk  did  not  demonstrate  the  nature  of  the 
organ. 

This  kind  of  aneurism  has  been  observed  in  the  arteries  of  me- 


AUTERY,  ARTERIAL  TISSUE. 


101 


diiim  calibre,  or  those  of  the  fourth  and  fifth  orders,  as  the  iliac,  the 
carotids,  the  brachial,  the  femoral,  the  tibial ; and  in  vessels  still 
smaller,  or  those  of  the  sixth  order,  as  the  occipital,  auricular,  radial, 
ulnar ; in  the  palmar  and  plantar  arches ; and  in  the  ophthalmic 
artery. 

Sometimes  in  arterial  varix,  amidst  a very  dilated  flexuosity  of 
the  artery,  we  observe  a sudden  contraction,  and  for  some  inches 
of  its  length,  the  vessel  preserves  its  natural  volume. 

Arterial  varix  is  distinguished  from  aneurism  by  anastomosis, 
by  the  irregularity  of  the  dilatations  which  it  presents. 

It  is  distinguished  from  venous  varix  in  the  living  body  by  the 
pulsations  of  the  dilated  vessels. 

A state  quite  similar  to  that  of  cirsoid  aneurism  is  observed  in 
old  varicose  aneurism,  or  aneurism  resulting  from  the  simultane- 
ous lesion  of  an  artery  and  of  a vein  in  the  same  point  by  the  same 
instrument,  from  the  interchange  of  the  blood  of  the  two  vessels, 
but  especially  from  the  passage  of  the  venous  blood  into  tlie  artery. 

Next  to  the  retardation  in  the  artery  of  the  blood  below  the 
wound,  the  dilatation  of  the  whole  of  that  part  of  the  external  sys- 
tem, the  weakening  of  the  pulsations,  the  diminution  of  tempera- 
ture in  the  parts  below  the  opening  of  communication  between  the 
two  orders  of  vessels,  the  violet  hue  of  the  same  parts ; lastly,  the 
less  brilliant  colour  of  the  blood  in  the  lower  end  of  the  artery 
when  it  is  examined  before  the  application  of  ligatures,  and  the 
entrance  of  the  venous  blood  into  the  artery  during  the  diastole  of 
this  vessel,  are  the  circumstances  which,  according  to  Breschet, 
leave  no  doubt  on  the  nature  of  the  disease  and  its  causes,  viz.  in- 
terchange of  the  two  kinds  of  blood. 

This  analogical  circumstance  under  the  relation  of  the  organic 
change  in  the  arterial  varix  and  old  varicose  aneurism,  leads  na- 
turally to  the  idea,  that  in  arterial  varix  there  may  be  a communi- 
cation between  the  two  orders  of  vessels  and  the  passage  of  a cer- 
tain quantity  of  the  venous  blood  into  the  dilated  and  varicose  ar- 
tery. A case  by  Pearson  would  lead  to  the  same  inference. 

9.  Wounds  and  their  consequences.  An  artery  may  be  punctured, 
perforated,  cut  longitudinally,  divided  partially  or  entirely  across, 
or  torn  completely  asunder. 

In  the  first  three  cases  the  blood  which  escapes  is  injected  into 
the  filamentous  sheath,  and  coagulating,  prevents  further  effusion 
from  the  vessel.  In  a few  hours  the  edges  of  the  wound  inflame, 
and,  pouring  out  lymph,  are  united  by  adhesion.  In  the  case  of 


102 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


small  wounds,  especially  longitudinal,  this  union  may  be  effected 
without  obliteration  of  the  canal.  But  when  the  wound  is  large  or 
oblique,  if  the  inflammation  is  sufficient  to  effect  union  and  prevent 
further  hemorrhage,  so  much  lymph  is  effused,  that  in  general, 
with  the  pressure  and  rest  requisite,  the  opposite  sides  of  the  vessel 
adhere,  and  its  canal  is  for  some  space  obliterated.  (Jones,  Hodg- 
son.) 

In  most  cases,  however,  of  longitudinal  or  oblique  wounds,  and 
in  all  cases  of  partial  transverse  wounds,  the  process  is  different. 
Supposing  the  external  opening  to  be  closed,  which  it  sooner  or 
later  is,  the  blood  from  the  wounded  artery  is  extensively  injected 
into  the  sheath,  where  its  coagulation  prevents  as  before  further 
effusion.  Though  inflammation  takes  place,  however,  and  lymph 
is  effused,  it  is  insufficient  to  unite  permanently  the  divided  edges. 
Either  the  wound  is  never  thoroughly  united,  or  at  a period  after 
its  infliction,  varying  according  to  its  extent  and  direction,  and  ac- 
cording to  the  size  of  the  artery  and  its  distance  from  the  heart,  its 
edges  are  rent  asunder  by  the  incessant  impulse.  (Jones,  Hodg- 
son, Guthrie.)  Blood  continues  from  time  to  time  to  escape  into 
the  sheath,  which  it  distends  into  a sac,  and  in  which  it  is  deposited 
in  successive  layers.  In  this  manner  is  formed  a pulsating  tumour, 
which  has  been  termed  false,  spurious,  or  bastard  aneurism.  (Monro 
Pi  imus.)  If  the  injection  is  extensive,  so  as  to  cause  a diffuse 
swelling,  spreading  to  some  distance  along  the  limb,  the  disease  is 
termed  diffuse  aneurism.  If  it  is  more  limited,  distends  the  sheath 
into  a globular  sac,  and  assumes  the  appearance  of  the  usual  aneu- 
rismal  tumour,  then  it  is  termed  circumscribed  aneurism.  This  is 
the  sort  of  aneurism  which  takes  place  when  the  brachial  artery  is 
opened,  instead  of  the  vein  at  the  bend  of  the  arm  ; (William  Cow- 
per,  Macgill,  Monro  Primus^  &c.)  and  it  is  not  uncommon  in  the 
temporal  artery,  when,  that  vessel  has  been  opened  to  discharge 
blood  for  affections  of  the  head.  It  may,  however,  succeed  punc- 
tured wounds,  especially  sword-thrusts  in  any  part  of  the  body.  In 
short,  every  cause  which  partially  wounds  or  injures  the  side  of  an 
artery,  as  a sharp  spicula  of  bone,  may  be  followed  by  false  aneu- 
rism. At  the  bend  of  the  arm  it  is  to  be  distinguished  from  aneu- 
rismal  varix  and  varicose  aneurism. 

When  an  artery  is  entirely  divided  across,  the  result  varies  ac- 
cording to  the  size  of  the  vessel.  The  moment  the  division  is  com- 
pleted, a copious  gush  of  blood  issues  from  the  vessel,  the  divided 


.yjTEKY,  AETEEIAL  TISSUE. 


103 


portions  mutually  recede  with  more  or  less  force,  and  the  walls  of 
the  vessel  collapse  so  as  to  contract  its  area  uniformly  from  the 
circumference  to  the  centre.  Of  the  two  latter  actions  the  former 
is  limited  by  the  attachment  of  the  proper  arterial  tissue  to  the  fila- 
mentous sheath.  But  notwithstanding  this  limitation,  so  forcible  is 
the  retraction,  as  it  is  termed,  that  the  connecting  fibres  of  the  fila- 
mentous sheath  are  always  rent  for  some  small  space  from  the  cut 
ends  of  the  tube.  The  annular  contraction,  or  centi’al  diminution 
of  the  area,  is  also  counteracted  by  the  longitudinal  impulse  of  the 
blood ; and  in  large  vessels  this  resistance  to  the  central  contrac- 
tion is  so  great,  that  the  latter  has  little  or  no  sensible  influence  in 
suppressing  hemorrhage.  In  such  circumstances  the  chief  agents 
of  this  process  are  the  pressure  of  coagulated  blood  etfused  into  the 
sheath,  {coagulum  externum^)  and  a conical  or  cylindrical  plug  of 
the  same  material  {coagulum  internuvi,)  within  the  mouth  of  the 
divided  vessel.*  When  by  the  formation  of  this  double  clot  a tem- 
porary check  to  the  transit  of  blood  is  given,  inflammation  and 
lymphy  exudation  from  the  divided  edges  tend  to  supply  the  means 
of  permanent  suppression.  When  this  fails  false  aneurism  is  the 
consequence. 

In  the  case  of  small  vessels  the  annular  contraction  bears  a larger 
proportion,  cocteris paribus^  to  the  size  of  the  vessel ; and  it  exercises 
a greater  influence  in  arresting  the  current  of  blood  through  the 
divided  orifice.  With  the  pressure  of  the  external  and  internal 
clots,  and  the  recession  of  the  divided  portions,  this  annular  con- 
traction is  in  general  amply  sufficient  to  stop  permanently  the  ef- 
fusion of  blood  from  small  vessels.  Hence  in  partial  wounds  of 
such  vessels  as  the  radial,  the  ulnar,  and  the  temporal  arteries,  the 
entire  division  of  the  vessel  is  often  the  most  effectual  means  of 
checking  the  flow  of  blood  from  them.  In  amputation  also,  in 
which  the  arteries  are  divided  transversely,  the  smaller  vessels  may 
be  left  untied  without  danger. 

The  principle  now  laid  down  Dr  L.  Koch  of  Munich  has  at- 
tempted to  carry  to  a much  greater  length.  Denying  that  hemor- 
rhage, from  arteries  entirely  divided,  is  suppressed  in  the  manner 
now  mentioned,  denying  especially  the  formation  of  the  double  clot 

* “ The  mouth  of  the  artery  being  no  longer  pervious,  nor  a coUateral  branch  very 
near  it,  the  blood  just  within  it  is  at  rest,  coagulates,  and  forms  in  general  a slender 
conical  coagulum,  which  neither  fills  up  the  canal  of  the  artery,  nor  adheres  to  its 
sides,  except  by  a small  portion  of  the  circumference  of  its  base,  which  lies  near  the 
extremity  of  the  vessel.”- — Jones  on  Hemorrhage,  Chap.  I.  sect.  iii.  p.  S3. 


104 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


as  a uniform  result  of  transverse  division,  he  has  recourse  to  the 
supposition  of  a peculiar  force  and  action  to  account  for  the  cessa- 
tion of  hemorrhage.  He  denies  the  necessity  of  ligature  in  any 
case,  and  proposes  to  leave  large  as  well  as  small  vessels  untied. 
His  arguments  are  manifestly  derived  from  the  phenomena  of  the 
division  of  small  arteries  only,  and  cannot  therefore  be  justly  ap- 
plied to  large  ones.  I have  already  shown,  that  in  the  case  of  the 
former  the  annular  contraction  is  the  main  agent  of  the  cessation 
of  hemorrhage ; and  to  this,  I conceive,  corresponds  the  peculiar 
force  to  which  Dr  Koch  ascribes  that  process.* 

When  an  artery  is  lacerated  or  forcibly  rent  asunder,  the  same 
process  of  injection,  coagulation,  retraction,  and  annular  constric- 
tion take  place,  but  more  powerfully  and  more  speedily  than  in  the 
case  of  the  same  artery  divided  transversely  by  a cutting  instru- 
ment. The  external  clot  especially  is  formed  very  rapidly ; the 
internal  one  is  large  and  extensive ; and  the  annular  contraction 
of  the  lacerated  vessel  is  much  more  considerable.  (Guthrie  and 
others.)  These  circumstances  afford  an  explanation  of  the  well- 
established  fact,  that  any  artery,  when  forcibly  rent  asunder,  bleeds 
infinitely  less  than  the  same  vessel  completely  divided  by  a trans- 
verse incision.  So  uniform  is  this  fact,  that  arteries  of  moderate 
size  have  been  torn  by  a transverse  laceration  without  effusing 
more  than  a few  drops  of  blood. 

10.  Aneurismal  Varix.  It  sometimes  happens  that  an  artery  sub- 
jacent to,  and  in  immediate  contact  with  a vein,  is  punctured  by  the 
same  instrument  with  which  the  vein  has  been  perforated,  and  the 
wound  thus  inflicted  establishes  between  the  two  vessels  a commu- 
nication, tlu’ough  which  the  blood  passes  from  the  one  to  the  other. 
Thus,  from  want  of  caution  on  the  part  of  the  operator,  it  may 
happen  that  in  venesection  at  the  bend  of  the  arm,  the  lancet  may 
not  only  transfix  the  vein,  but  wound  the  subjacent  artery.  The 
blood  flows  from  the  latter  into  the  former  with  a peculiar  hissing 
noise,  and  dilates  it  into  a sack  which  disappears  on  pressure,  but 
returns  when  the  pressure  is  removed.  The  tumour  thus  formed, 
which  depends  on  the  wound  of  the  arterial  and  venous  tunic  re- 
maining open  while  their  sides  are  in  contact,  was  first  distinguish- 
ed as  a peculiar  affection  by  William  Hunter,|  and  is  known  un- 
der the  name  of  aneurismal  varix.  It  may  occur  in  any  part  of 

■*  Journal  fiir  Chinirgie  und  Augenheilkunde  von  Graefe  und  M^altlier,  p.  9,  t.  560. 

t Aledical  Observations  and  Inquiries,  Vol.  II.  p.  396,  400. 

4 


ARTERY,  ARTERIAL  TISSUE. 


105 


the  vascular  system  in  which  a vein  lies  immediately  over  an  arte* 
rial  trunk.  In  most  of  the  cases  hitherto  recorded  it  has  continued 
for  years  (five.  Hunter,  Cleghorn  ; fourteen,  Hunter,  Scarpa, 
Bell ; twenty-five,  thirty-five.  Bell,  Hunter ;)  without  serious  in- 
convenience. 

1 1 . Varicose  aneurism.  In  the  case  of  an  artery  lying  beneath,  but 
not  in  immediate  contact  with  a vein,  or  in  the  case  of  the  wound 
being  oblique  and  the  puncture  of  the  vein  not  corresponding  to 
that  of  the  artery,  the  same  accident  is  followed  with  another  va- 
riety of  tumour.  The  blood  from  the  arterial  tube  flows  partly  into 
the  sheath,  which  is  distended  into  a sac,  and  partly  into  the  vein, 
which  is  morbidly  dilated.  The  tumour  thus  resulting,  the  anato- 
mical characters  of  which  are  a circumscribed  aneurism  between 
the  artery  and  vein,  and  a varicose  state  of  the  latter,  has  been  dis- 
tinguished as  varicose  aneurism.* 

The  filamentous  sheath,  though  not  proper  to  the  arterial  tissue, 
performs,  nevertheless,  an  important  part  in  the  morbid  states  of 
arteries,  whether  spontaneous  or  resulting  from  injuries.  It  has 
been  already  shown  what  is  its  influence  in  the  production  of  ge- 
nuine aneurism,  in  the  suppression  of  hemorrhage,  and  in  the  for- 
mation of  the  several  varieties  of  false  or  spurious  aneurisraal  tu- 
mours. It  is  liable  further  to  the  same  forms  of  inflammatory  ac- 
tion as  attack  this  tissue  in  other  parts  of  the  animal  frame.  But 
inflammation  here  is  often  attended  with  the  bad  efiect  of  produc- 
ing ulceration  of  the  middle  coat,  and  laceration  succeeded  by  he- 
morrhage more  or  less  violent,  according  to  the  size  of  the  vessel. 
This  process,  which  depends  on  the  destruction  of  the  nutrient  ves- 
sels {vasa  vasorum)  transmitted  in  the  filamentous  coat,  may  suc- 
ceed any  injury  inflicted  on  the  neighbouring  parts,  as  contused 
wounds,  burns,  phagedenic  sores,  especially  those  in  lymphatic 
glands,  the  application  of  improper  ligatures,  especially  broad  tapes, 
and  the  use  of  foreign  bodies  as  pads,  presse-arferes  and  serre-ar- 
teres  in  the  neighbourhood  of  an  artery.  Removal  of  the  filamen- 
tous sheath,  partly  or  entirely,  is  not  unfrequently  followed  with  the 
same  effect.  This,  however,  must  be  understood  to  apply  chiefly 
to  the  human  subject.  In  the  lower  animals  the  filamentous  sheath 
may  be  removed  without  injuring  the  proper  and  inner  membrane. 

* Paik  in  Bledical  Facts  and  Observations,  Vol.  IV.  p.  Hi.  Phvsick  in  Medical 
Museum,  Philadelphia,  Vol.  I.  p.  65. 


106 


GENEKAL  AND  PATHOLOGICAL  ANATOMY. 


(Hunter  and  Home.)*  This  shows  that  in  these  circumstances  its 
inflammation  is  not  attended  with  the  bad  efiects  which  result  in 
the  human  subject. 

1 2.  Obstruction  in  the  cavity  of  arteries.  Occlusio  arteriarum;  op- 
pilatio  arteriarum.  The  deposits  and  growths  already  mentioned, 
whether  tubercular  or  wart-like,  or  atheromatous,  steatomatous,  or 
calcareous,  all  tend  to  diminish  more  or  less  the  calibre  of  the  ar- 
tery, and  to  cause  more  or  less  obstruction  to  the  motion  of  the 
blood.  It  is  true  that  soon  after  deposits  of  any  of  these  growths 
have  taken  place,  there  appears  at  their  site  to  be  a sort  of  bulging 
of  the  arterial  tube,  or  a dilatation  general  or  partial ; and,  in  point 
of  fact,  this  often  takes  place  with  at  the  same  time  a certain  degree 
or  dilatation  internally.  This  appears  to  be  the  result  of  the  im- 
pediment which  the  blood  encounters  in  passing  over  diseased  por- 
tions of  an  arterial  tube  ; for  as  tbe  blood  meets  greater  resistance, 
it  is,  especially  in  the  aorta,  propelled  with  greater  force ; and  in 
almost  the  whole  of  these  cases  in  which  the  interior  of  the  aorta 
is  thus  diseased,  the  left  ventricle  of  the  heart  is  more  or  less  hy- 
pertrophied. 

It  also  happens,  however,  that  these  new  growths  may  by  their 
number  and  size  diminish  in  a greater  or  less  degree  the  calibre  of 
the  arterial  cylinder.  Thus  in  the  case  recorded  by  Stentzel,  the 
atheromatous  or  steatomatous  tumour  had  greatly  contracted  the 
dimensions  of  the  canal  of  the  aorta. | In  a case  given  by  the  elder 
IMeckel,  the  diameter  of  the  aorta  in  an  aged  female  was  not  more 
than  eight  lines,  from  a similar  cause.J  Sandifort  mentions  the 
case  of  a man  in  whom  a similar  deposition  in  the  interior  of  the 
aorta  had  contracted  much  the  calibre  of  the  artery.  Stoerck  states 
that  in  inspecting  the  body  of  a female,  aged  64,  who  had  long  la- 
boured under  diflicult  breathing  and  palpitation  of  the  heart  on 
making  any  exertion,  and  who  died  in  syncope,  he  found  the  arch 
of  the  aorta  completely  bony,  and  the  tunics  thickened,  and  the 
canal  of  the  artery  so  small  that  it  would  not  admit  the  little  finger. 
This  form  of  obstruction  is  generally  partial. 

In  the  progress  of  those  changes  which  take  place  in  aneurism, 
the  calibre  of  an  artery  may  be  so  much  contracted,  and  its  interior 

* Transactions  of  a Society  for  improving  Medical  and  Chirurgical  Knowledge,  Vol. 
I.  p.  144. 

t Chris.  Gottff.  Stentzel  de  Steatomatibus  Aortae.  Wittembergse,  1732. 

X Haller,  Dissert.  Medico-Practice,  Tom.  ii. 

3 


AETERY,  ARTERIAL  TISSUE. 


107 


so  much  obstructed,  as  to  impede  much  the  motion  of  the  blood 
through  it.  The  obstruction  is  caused  not  only  by  atheromatous 
and  steatomatous  growths  adhering  to  the  artery,  but  by  deposits 
of  blood  and  lymph  or  fibrin  adhering  to  the  internal  surface  of  the 
vessel  previously  diseased,  most  commonly  in  a state  of  ulceration. 

The  obstruction  may  be  partial,  and  confined  to  one  side  of  the 
vessel ; or  it  may  be  general,  extending  nearly  all  round,  but  not 
thoroughly  closing  the  canal  of  the  vessel ; or  it  may  be  complete, 
closing  altogether  the  tube  and  preventing  the  blood  from  flowing 
along  it. 

Partial  obstruction  is  mostly  seen  in  large  vessels,  as  the  aorta, 
the  innorainata,  the  thoracic  and  abdominal  aorta,  or  in  the  com- 
mon iliacs,  or  the  common  carotid,  or  the  subclavian  artery. 
General  obstruction  also  occurs  in  these'vessels  though  more  rarely ; 
and  is  usually  in  vessels  belonging  to  the  third  class,  which  are  of 
smaller  size.  Partial  and  general  obstruction  mostly  takes  place 
either  in  consequence  of  steatomatous  deposits  in  the  interior  of  the 
artery,  or  the  deposition  of  blood  and  lymph  in  the  progressive 
changes  which  occur  in  aneurismal  tumours,  which  pressing  more 
or  less  completely  on  the  part  of  the  artery  on  which  they  take 
place,  retard  or  interrupt  the  flow  of  blood  through,  cause  thus  the 
formation  of  clots,  and  thereby  tend  to  diminish  much  the  calibre 
of  the  arterial  cylinder. 

Complete  obstruction  to  the  interior  of  an  artery  may  take  place 
under  the  same  circumstances  as  partial  and  general  obstruction. 
That  is,  the  blood  and  lymph  deposited  in  an  aneurismal  tumour 
and  within  the  arterial  canal  above  it,  may  be  so  arranged  as  to 
compress  the  vessel  and  interrupt  or  obstruct  entirely  the  course  of 
the  blood  through  the  artery.  Such  was  the  case  in  the  instance 
recorded  by  Larcheus,  which  I have  elsewhere  described  ;*  in  that 
published  by  Dr  Crampton,  and  that  by  Dr  Monro.  In  cases  of 
this  nature,  one  of  two  eflects  may  ensue.  First,  the  artery  dis- 
tended with  blood,  which  is  allowed  neither  to  flow  through  the 
trunk  nor  to  escape  by  collateral  branches,  may  burst,  and  the  ac- 
cident may  prove  fatal.  This  is  by  far  the  most  common  termina- 
tion when  the  arterial  canal  is  so  much  obstructed.  Thus  I have 
seen  the  abdominal  aorta  burst  above  an  aneurismal  tumour,  and 

* Instance  of  Obliteration  of  the  Aorta  beyond  the  Arch.  Illustrated  by  similar 
Cases  and  Observations.  By  Dawd  Craigie,  M.  D.,  &c.  Edin.  Medical  and  Surgical 
Journal,  Vol.  LVI.  p.  A27. 


108 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  blood  escaping  tear  and  dissect  away  the  whole  peritoneum 
from  the  subjacent  muscles.  The  same  appears  to  have  taken  place 
in  the  case  given  by  Fantoni.  Secondly,  in  consequence  of  the 
blood  not  passing  through  the  arterial  tube,  the  parts  to  which  it 
is  distributed  are  deprived  of  their  nutrient  fluid,  and  become  at 
first  cold,  numb,  and  slightly  paralytic ; afterwards  they  become 
unusually  hot;  and  gangrenous  inflammation  is  rapidly  developed 
and  terminates  in  mortification. 

A species  of  complete  obstruction  liable  to  take  place  in  arteries 
previously  diseased,  especially  in  the  extremities,  is  that  which 
takes  place  in  cases  of  gangrene  of  the  toes  in  the  aged,  {gancjrcKna 
senilis,)  and  which  has  been  described  as  a form  of  inflammation  of 
the  arteries  (^arteritis)  by  Dupuytren.  The  interior  of  the  artery 
is  filled  with  clots  of  blood,  generally  Arm  and  solid,  and  often  ex- 
tending through  the  greater  part  or  the  whole  of  the  arterial  trunk. 
Thus  it  may  extend  through  the  femoral  artery  from  the  ligament 
of  Poupart  to  the  loin,  and  sometimes  the  tibial  and  femoral  arte- 
ries are  filled  with  solid  clots  of  blood  of  the  same  kind.  The  ar- 
terial tube  is  generally  firm,  indurated,  penetrated  or  lined  by 
atheromatous  or  steatomatous  specks  or  osseous  matter,  indicating 
that  it  has  been  in  a state  of  chronic  inflammation.  This  disease, 
therefore,  is  to  be  considered  rather  as  an  effect  of  chronic  inflamma- 
tion than  acute  inflammation.  In  general  the  first  indications  of  the 
formation  of  coagula,  are  pains  in  the  limb,  numbness,  and  then  the 
artery  is  observed  to  have  ceased  to  beat.  This  is  followed  by  the 
usual  symptoms  of  gangrenous  inflammation  ; — pain,  heat,  redness, 
lividity,  phlyctaenae  or  vesications,  and  death  of  the  limb,  followed 
by  general  death.  In  milder  cases,  one  or  two  toes  only,  or  the 
foot  may  be  affected,  and  the  limb  vt'ith  life  is  saved. 

A species  of  obstruction  apparently  complete,  though  in  several 
instances  temporary  in  duration,  I have  seen  take  place  in  the  ar- 
teries of  the  extremities.  A female,  between  20  and  25,  labour- 
ing under  rheumatism  of  the  ankles  and  wrists,  with  slight  indica- 
tions of  affection  of  the  pericardium  or  endocardium,  was  suddenly 
attacked  with  numbness  and  loss  of  power  and  sensation  in  the  left 
arm ; and  when  it  was  examined  no  pulsation  w’as  recognised  either 
in  the  radial  artery  or  the  liumeral,  to  within  two  inches  of  the 
axilla,  or  in  the  ulnar  artery.  These  sensations  were  attended  with 
weight  of  the  arm  and  occasional  pains,  pricking  and  lancinating. 
Warmth  was  applied  externally.  The  symptoms,  however,  con- 


ARTERY,  ARTERIAL  TISSUE. 


109 


tinued  for  about  eight  days,  and  after  that  time  gradually  subsided. 
Pulsation  returned  feebly  to  the  radial  artery,  but  not  to  the  hu- 
meral. The  patient  after  some  time  recovered,  and  remained  well 
for  years,  though  with  some  feebleness  and  numbness  in  the  left 
arm.  Though  I have  not  the  evidence  of  dissection,  therefore,  yet 
I infer  that  this  was  obstruction  in  the  humeral  artery,  probably 
by  slight  inflammation  taking  place  in  its  coats  and  causing  effusion 
of  lymph,  and  the  formation  of  an  obstructing  clot  of  blood.  A 
case  very  similar,  illustrated  by  inspection  of  the  parts,  is  given  by 
Dr  Graves  in  the  Dublin  Hospital  Reports,  Vol.  V.  p.  1 ; (case  of 
Patrick  Magrath),  and  one  without  inspection  by  Dr  Gairdner  in 
the  Edinburgh  Medico-Chirurgical  Transactions,  Vol.  III. 

Obstruction  of  arteries  may  also  ensue  as  the  effect  of  external 
pressure,  as  the  effect  of  tumours  increasing  in  size  and  encroach- 
ing on  the  space  occupied  by  the  artery.  Thus  when  a small  ar- 
tery, as  the  temporal,  is  opened  and  afterwards  subjected  to  com- 
pression, in  general  its  interior  is  obstructed,  sometimes  adhering 
and  obliterated.  Encephaloid  tumours  of  the  chest  or  abdomen 
compress  and  obstruct  the  abdominal  aorta ; exostosis  of  the  ver- 
tebrse  compress  the  thoracic  and  abdominal  aorta  and  obstruct  the 
interior ; exostoses  of  the  cranium  and  tumours  within  the  brain 
have  been  observed  to  compress  and  obstruct  the  branches  of  the 
internal  carotid  and  vertebral  arteries ; and  I have  seen  in  tumours 
of  the  uterus  and  cancerous  swellings  the  posterior  iliac  artery  and 
its  branches  closed  and  its  interior  obstructed. 

13.  Obliteration.  From  complete  obstruction  the  transition  to 
obliteration  of  arteries  is  easy.  The  result  is  the  same;  but  the  mode 
in  which  it  is  accomplished  is  different  In  obstruction  tbe  closure 
or  impediment  is  caused  by  the  presence  either  of  new  growths  or 
blood  and  lymph  within  the  artery  and  the  arterial  tunics.  In  ob- 
literation the  impediment  or  arctation  of  the  canal  is  caused  not  so 
much  by  internal  growths  as  by  the  approximation  of  the  arterial 
walls,  in  consequence  of  external  pressure,  or  some  similar  agent. 
Hence  the  cases  of  obstruction  which  I mentioned  at  the  close  of  the 
preceding  paragraph  may  be  regarded  as  examples  of  obliteration. 

Of  obliteration  of  arteries  there  are  several  forms  and  sorts ; 
and  the  accident  may  take  place  in  any  artery  almost,  of  any  class. 
It  is  nevertheless  more  frequent  in  vessels  of  the  second,  third,  and 
fourth  class,  for  very  obvious  reasons,  than  in  those  of  the  first  class. 
Arteries  become  obliterated  in  consequence  of  pressure  of  any  kind, 
the  presence  of  coagula  in  their  interior  either  in  consequence  of 


110 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


inflammation  or  similar  causes,  and  in  consequence  of  the  applica- 
tion of  ligatures,  all  arterial  canals  being  obliterated  a little  above 
and  a little  below,  sometimes  a good  space  from  the  point  at  which 
the  ligature  has  been  applied. 

14.  Arctation  or  Obliteration  of  the  Aorta  at  the  definite  point 
The  species  of  obliteration,  or  sometimes  only  of  obstruction, 
which  here  deserves  notice,  is  one  which  takes  place  always  at  a 
definite  or  fixed  point  in  the  aorta.  This  consists  in  a peculiar 
arctation  or  contraction  of  the  aorta,  in  the  arch  at  its  farther  end, 
or  rather  at  that  point  of  the  arch  which  is  beyond  the  origin  of 
the  left  carotid  and  left  subclavian  arteries.  Of  this  species  of  ob- 
literation I met  with  one  case  in  my  own  sphere  of  observation : and 
I have  collected  from  various  sources  other  nine  cases ; and  since 
that  time  three  or  four  more  cases  have  been  published,  so  that 
thirteen  cases  altogether  have  now  been  recorded  and  described. 
In  the  whole  of  these  cases  the  arctation  or  contraction  was  observed 
at  the  point  specified,  viz.  where  the  ductus  arteriosus^  converted 
into  a ligament,  joins  the  aorta.  It  appears  in  the  form  of  a deep 
annular  indentation  surrounding  the  entire  cylinder  of  the  artery, 
though  sometimes  more  deep  at  one  side  than  at  another  ; and  in 
almost  all  the  cases  this  indentation  is  greatest  towards  the  convex 
side  of  the  vessel,  and  least  towards  the  concave  and  the  attachment 
of  the  ductus  arteriosus.  In  general  the  arch  of  the  aorta  becomes 
small  immediately  after  giving  off  the  left  carotid  and  left  subclavian, 
and  diminishes  greatly,  though  progressively,  to  the  point  of  oblite- 
ration. In  some  cases  the  aorta  at  the  point  of  obliteration  and  for 
some  space  around  it,  is  lined  or  penetrated  with  osteo-steatoma- 
tous  matter,  and  is  much  indurated.  (Otto’s  Case,  Craigie’s  Case.) 

When  I published  the  first  edition  of  this  work,  and  when  the 
only  known  cases  were  those  by  M.  Paris,  Dr  Graham,  Mr  Win- 
stone,  M.  Otto,  and  A.  Meckel  of  Bern,  though  the  phenomena 
of  these  cases  satisfied  me  of  the  peculiar  nature  of  the  arctation  of 
the  aorta,  yet  it  would  have  been  premature  to  have  drawn  from  so 
small  a number  of  facts  the  conclusions  which  I have  since  been 
enabled  to  deduce.  From  comparing  the  whole  ten  cases,  and 
considering  what  I observed  in  the  case  dissected  by  myself,  I in- 
fer that  the  contraction  and  obliteration  when  it  takes  place,  de- 
pends on  the  same  action  which  closes  the  ductus  arteriosus  being 
extended  into  the  aorta.  It  must  be  remembered  that  in  the  foetus 
the  pulmonary  artery,  consists,  as  it  were,  of  three  branches,  one 
going  to  the  right  lung,  one  to  the  left,  both  small,  and  one  to  the 


ARTERY,  ARTERIAL  TISSUE. 


Ill 


aorta,  the  largest  and  most  capacious  of  the  three.  Through 
the  two  former  little  or  no  blood  flows ; through  the  latter  a large 
quantity  flows,  almost  directly  from  the  right  ventricle  into  the  ab- 
dominal aorta,  or  that  portion,  of  the  aorta  below  the  entrance  of 
the  ductus  arteriosus.  At  birth  and  after  that  event,  in  consequence 
of  the  lungs  being  developed  and  subjected  to  the  action  of  respi- 
ration, the  blood  from  the  right  ventricle  proceeds  along  the  pul- 
monary artery  and  its  two  divisions,  which  are  now  enlarged  and 
daily  enlarging,  while  the  third  branch,  or  ductus  arteriosus,  under- 
goes rapid  contraction.  The  point  at  which  the  duct  joins  the  aorta  is 
fixed,  and  keeps  the  aorta  there  as  it  were  immovable.  Meanwhile 
the  walls  of  the  duct,  in  consequence  of  little  or  no  blood  passing 
through  them,  mutually  approximate,  and  at  length  adhere,  produc- 
ing obliteration.  The  same  action  may  extend  into  the  aorta,  the 
more  liable  to  undergo  contraction,  that  at  the  very  time  at  which 
the  large  current  of  blood  is  diverted  into  the  two  branches  of  the 
pulmonary  artery,  little  passing  along  the  ductus  arteriosus,Yiit\Q  also 
must  flow  through  this  part  of  the  aorta.  This  action  once  begun 
has  only  to  continue.  It  does  not  require  to  be  increased.  If  it 
continue,  while  the  other  parts  of  the  aorta  and  the  arterial  system 
are  enlarging,  this  remains  stationary,  or  in  the  foetal  condition  and 
dimensions.  If  this  only  continue,  obliteration  at  that  point  is  the 
inevitable  result. 

Meanwhile  the  blood  is  maintaining  its  old  channels  which  it  pre- 
served previous  to  birth,  and  rendering  them  larger  and  more 
suited  to  the  exigencies  of  extra-uterine  life.  The  superior  and  in- 
ferior intercostal  arteries,  the  transverse  cervicals,  the  mammary 
above ; and  below,  the  epigastric  and  circumflex  arteries  of  the 
ilium,  with  the  lumbar  arteries,  are  found  very  much  enlarged,  and 
to  have  constituted  the  means  of  conveying  blood  from  the  heart  to 
the  inferior  portion  of  the  trunk  and  to  the  lower  extremities. 
These  changes  are  evidently  effected  in  early  life,  in  short,  in  in- 
fancy, and  increase  with  the  growth  of  the  individual. 

The  facts  now  detailed  contain  a remarkable  example  of  a defect 
or  impediment  in  the  arterial  system,  which  might  be  inferred,  from 
om’  knowledge  of  that  system,  to  be  incompatible  with  the  continu- 
ance of  life  and  the  enjoyment  of  good  health.  They  also  show 
the  remarkable  provision  by  which  the  pernicious  effects  of  so  great 
a lesion  are  very  nearly,  if  not  completely,  obviated  and  counter- 
acted. It  appears  that  the  lesion  has  little  tendency  to  abridge  the 
duration  of  human  life;  for  two  persons  attained  the  age  of  50  years. 


112 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


one  of  57,  one  that  of  60,  and  one  the  extraordinary  length  of  90  years. 
It  appears,  nevertheless,  that  all  of  the  subjects  of  this  lesion  had  been 
either  exposed  to  cold,  or  were  labouring  under  the  effects  of  ca- 
tarrh, attended  with  symptoms  of  dyspnoea,  constriction  in  the  chest, 
sometimes  pain  and  anxiety,  with  palpitation  of  unusual  violence 
and  severity;  and  amidst  attacks  of  this  nature  almost  all  of  them  ex- 
pired. This  shows  what  might  a priori  be  expected,  that  in  persons 
■with  such  a defect  or  lesion,  life  is  held  by  a precarious  and  uncer- 
tain tenure.  Among  the  ten  cases  recorded  by  me,  in  four  the 
immediate  cause  of  death  was  laceration  of  the  heart  or  aorta ; an 
event  attributable  to  the  impediment  encountered  by  the  blood  in 
passing  out  of  the  left  ventricle  into  the  aortic  arch. 

It  is  further  singular  that  with  so  great  an  impediment  to  the 
transit  of  the  circulating  fluid,  the  lower  extremities  were  well 
nourished : and  in  several  of  the  cases  the  persons  were  strong  and 
robust. 

Arteries  may  be  involved  in  the  diseases  of  muscles,  bones,  and 
other  parts,  and  in  the  progressive  invasion  of  foreign  or  new  pro- 
ductions. 


CHAPTER  VI. 

VEIN,  VENOUS  TISSUE,  (PAs-vj/.  ( Vena — Tissu  veneux.) 

Section  I. 

The  structure  of  the  tubular  canals,  termed  veins,  has  been 
much  less  examined  by  anatomists  than  that  of  the  arteries.  Some 
incidental  observations  in  the  writings  of  Willis,  Glass,  and  Clifton 
Wintringham,  comprise  all  that  was  published  regarding  them  pre- 
vious to  the  short  account  of  Haller.  Since  that  time  they  have 
been  described  with  various  degrees  of  minuteness  and  accuracy  by 
John  Hunter,  Bichat,  Magendie,  Gordon,  Marx,*  and  Meckel. 
In  the  following  account  the  facts  collected  by  these  observers  have 
been  compared  with  the  appearance  and  visible  organization  pre- 
sented by  veins  in  different  parts  of  the  human  body. 

The  veins  are  membranous  tubes  extending  between  the  right 

* Diatribe  Anatomico-pliysiologico  de  structura  atque  vita  venarum.  Carolii-ulias 
1819. 


VEIN,  VENOUS  TISSUE. 


113 


side  or  pulmonary  division  of  the  heart  and  the  different  organs  in 
which  their  minute  branches  are  ramified. 

Every  venous  tube  greater  than  one  line  in  diameter  consists  of 
three  kinds  of  distinct  substance.  The  outermost  is  a modification 
of  the  filamentous  tissue,  (membrana  cellulosa,^  and  though  less 
compact,  and  less  thick  than  the  arterial  filamentous  envelope,  is 
in  every  other  respect  quite  similar,  and  is  in  general  intimately 
connected  with  it.  The  innermost  {membrana  intima)  is  a smooth, 
very  thin  membrane.  Between  these  is  found  a tunic  somewhat 
thicker,  which  is  termed  the  proper  venous  tissue,  {tunica  propria 
vena.')  The  structure  and  aspect  of  this  proper  membrane  shall 
be  first  considered. 

1st,  When  the  loose  filamentous  tissue  in  which  the  blood-ves- 
sels are  inclosed,  and  the  more  delicate  and  firm  layer  immediately 
contiguous  to  the  veins,  are  removed,  the  observer  recognises  a red 
or  brown- coloured  membrane,  not  thick  or  strong,  but  somewhat 
tough,  which  is  the  outer  surface  of  the  proper  venous  tunic.  If 
dissected  clean,  it  is  tolerably  smooth ; but  however  much  so  it  can 
be  made,  a glass  of  moderate  powers,  or  even  a good  eye,  will  per- 
ceive numerous  filaments  adhering  to  it,  which  appear  to  be  the 
residue  of  the  cellular  envelope. 

According  to  Bichat  parallel  longitudinal  fibres,  forming  a very 
thin  layer,  may  be  distinguished  in  the  larger  veins;  but  he  ad- 
mits, although  they  are  quite  real,  that  they  are  always  difficult  to 
be  seen  at  tbe  first  glance.  In  the  trunk  of  the  inferior  great  vein, 
{vena  cava  inferior,)  they  are  always  seen,  he  observes,  more  dis- 
tinctly than  in  that  of  the  superior ; and  they  are  always  more  ob- 
vious in  the  divisions  of  the  former  than  in  those  of  the  latter  ves- 
sel, and  also  in  the  superficial  than  in  the  deep-seated  veins.  These 
longitudinal  fibres,  he  asserts,  are  more  distinct  in  the  saphena  than 
in  the  crural  vein,  which  accompanies  the  artery.  Lastly,  he  re- 
marks, these  fibres  are  proportionally  more  conspicuous  in  branches 
than  in  trunks.* 

Notwithstanding  the  apparent  correctness  of  this  description, 
Magendie  informs  us,  he  has  sought  in  vain  for  the  fibres  of  the 
proper  venous  membrane ; and  he  remarks,  that,  though  he  has 
observed  very  numerous  filaments  interlacing  in  all  directions,  yet 
these  assume  the  longitudinal  and  parallel  appearance  only  when 

* Anatomie  Generale,  Tom.  I.  p.  399. 

H 


114 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  tube  is  folded  longitudinally, — a disposition  often  seen  in  the 
larger  veins. 

By  Meckel,  on  the  contrary,  the  accuracy  of  the  observation  of 
Bichat  is  maintained.  This  anatomist  states  that  he  has,  by  the 
most  minute  dissections,  assured  himself  that  these  fibres  are  longi- 
tudinal ; but  he  admits  that  they  are  not  uniformly  present  in  all 
parts  of  the  venous  system,  and  that  in  degree  and  abundance  they 
are  liable  to  great  variation.  He  follows  Bichat  also  in  represent- 
ing these  fibres  as  thicker  and  more  distinct  in  the  system  of  the 
inferior  than  in  that  of  the  superior  cava^  and  in  the  superficial 
than  in  the  deep  veins. 

In  the  inferior  cava  of  the  human  subject,  certainly  filaments  or 
fibres  may  be  recognised.  But,  instead  of  being  longitudinal,  they 
may  be  made  to  assume  any  direction,  according  to  the  manner  in 
which  the  filamentous  tissue  is  removed.  For  this  reason  probably 
these  fibres  are  to  be  viewed  as  part  of  the  filamentous  sheath.  In 
the  saphena  vein  of  the  leg  oblique  fibres  may  be  seen  decussating 
each  other ; but  it  is  doubtful  whether  these  belong  to  tbe  proper 
venous  tissue,  or  to  the  filamentous  covering. 

I have  repeatedly  seen  and  demonstrated  the  following  facts. 

If  the  vena  cava  descendens  be  cut  open  by  a longitudinal  inci- 
sion and  washed  in  pure  water,  there  is  seen  first  the  inner  mem- 
brane perfectly  smooth,  very  thin,  and  semitransparent,  so  much  so, 
that  it  cannot  be  detached  from  the  middle  coat,  without  the  risk 
of  bringing  some  of  the  latter  away.  Secondly,  longitudinal  fibres 
or  lines  running  along  the  middle  coat  in  its  substance  parallel  to 
the  axis  of  the  vein.  Thirdly,  when  the  cellular  coat  is  detached 
carefully  by  the  forceps,  there  is  seen  a moderately  thick  membra- 
nous layer  of  fawn-colour,  presenting  longitudinal  threads,  lines, 
or  fibres. 

The  same  can  be  seen,  though  much  less  distinctly,  in  several  of 
the  large  venous  trunks,  for  instance  the  iliac  and  common  femo- 
ral veins. 

The  nature  of  this  proper  membrane  or  venous  fibre,  as  it  is 
sometimes  named,  (Bichat,)  is  not  at  all  known.  Its  great  exten- 
sibility, its  softness,  its  want  of  elasticity  in  the  circular  direction, 
or  fragility,  its  colour  and  general  aspect,  distinguish  it  from  the 
arterial  tunic.  It  possesses  some  elasticity  in  the  longitudinal  di- 
rection, and  is  retracted  vigorously  when  stretched.  It  possesses 
considerable  resistance,  or  in  common  language  is  tough.  The 


VEIN,  VENOUS  TISSUE. 


115 


experiments  of  Clifton  Wintringham  show  that  it  sustains  a con- 
siderable weight  without  breaking,  and  that  this  toughness  is  greater 
in  early  life,  or  in  the  veins  of  the  young  subject,  than  at  a later 
period.*  In  short,  it  may  be  stated  as  a general  fact,  that  venous 
tissue,  though  thinner,  possesses  greater  elasticity  and  tenacity  than 
arterial  tissue.  According  to  the  experiments  of  the  same  inquirer 
this  property  depends  on  that  of  the  superior  density  of  the  venous 
tissue,  the  specific  gravity  of  the  matter  of  the  vena  cava  being  in- 
variably greater  than  that  of  the  aorta  in  the  same  subject,  both  in 
man  and  in  brute  animals. 

From  some  experiments  Magendie  is  disposed  to  consider  it  of  a 
Jibrinous  character.  But  it  exhibits  in  the  living  body  no  proof  of 
muscular  structure  or  irritable  power.  When  punctured  by  a 
sharp  instrument,  or  exposed  to  the  electric  or  galvanic  action,  it 
undergoes  no  change  or  sensible  motion. 

This  tunic  is  wanting  in  those  divisions  of  the  venous  system 
termed  sinuses,  in  which  its  place  is  supplied  by  portions  of  the 
hard  membrane  ; (dura  meninx.) 

2d,  The  inner  surface  of  any  vein  which  has  been  laid  open  and 
well  washed  is  found  to  be  smooth,  highly  polished,  and  of  a bluish 
or  blue-white  colour.  This  is  the  inner  or  free  surface  of  the  in- 
ner venous  membrane,  (membrana  intima.)  It  is  exceedingly  thin, 
much  more  so  than  the  corresponding  arterial  membrane,  much 
more  distensible  and  less  fragile.  It  bears  a very  tight  ligature 
without  giving  way  as  the  arterial  does ; but  it  also  sustains  con- 
siderable weight,  which  shows  that  it  is  tough  and  resisting.  This 
is  the  membrane  termed  by  Bichat  common  membrane  of  dark  or 
nnodena  blood.  According  to  the  views  of  this  anatomist  it  forms 
the  inner  or  free  surface  not  only  of  all  the  venous  twigs,  branches, 
and  trunks  composing  this  system  of  vessels,  but  it  is  extended  from 
the  superior  and  inferior  great  veins  over  the  inner  surface  of  the 
right  auricle  and  ventricle,  and  thence  over  that  of  the  pulmonary 
artery  and  its  divisions ; and  through  this  whole  tract  it  is  the  same 
in  structure  and  properties. 

This  doctrine  has  not  yet  been  controverted.  But  perhaps  it 
may  be  doubted,  both  with  regard  to  the  inner  arterial  membrane, 
that  the  inner  tunic  of  the  aorta  and  of  the  pulmonary  veins  is  quite 
the  same ; and  in  regard  to  this  inner  venous  membrane,  whether 
that  of  the  veins  in  general  is  quite  the  same  with  that  of  the  pul- 

* Experimental  Inquiry  on  some  parts  of  the  Animal  Structure.  London,  1140, 


116 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


raonary  artery.  The  subject  demands  further  research.  Mean- 
while strong  confirmation  is  found  in  the  interesting  remark  of 
Bichat,  that  the  osseous  or  calcareous  depositions  which  are  com- 
mon in  various  spots  of  the  inner  arterial  membrane,  and  especially 
at  the  mitral  and  aortic  valves,  are  never  found  in  the  inner  venous 
membrane,  or  at  the  tricuspid  valve,  or  in  the  semilunar  valves  of 
the  pulmonary  artery.  Have  these  depositions  been  found  inside 
the  pulmonary  veins,  and  not  inside  the  pulmonary  artery  ? This 
fact  is  still  wanting  to  complete  even  their  pathological  similarity. 

The  inner  or  common  venous  membrane  is,  however,  the  most 
extensive  and  the  most  uniform  of  all  the  venous  tissues.  It  is  the 
onl)^  one  which  is  found  in  the  substance  of  organs,  and  is  present 
where  the  cellular  and  proper  membrane  are  wanting.  This  is  the 
case  not  only  with  venous  branches  and  minute  canals  as  they  issue 
from  the  substance  of  muscles,  bones,  and  such  organs  as  the  liver, 
kidneys,  spleen,  &c.  but  is  also  very  remarkably  observed  with  re- 
gard to  the  venous  canals  of  the  brain.  I have  already  noticed 
the  absence  of  the  cellular  and  proper  tissues  in  these  tubes ; and 
I have  now  to  remark,  that  the  cerebral  veins  consist  solely  of  the 
inner  membrane,  while  in  the  brain  or  membranes,  and  when  in 
the  sinuses  of  this  inner  membrane,  placed  between  folds  of  the 
dura  mater.  When  the  jugular  vein  reaches  the  temporo-occipital 
sinuosity,  it  loses  its  proper  membrane,  while  its  common  or  inner 
membrane  passes  into  the  hollow  of  the  dura  mater.^  called 
and  thus  forms  the  venous  canal.  This  fact  is  readily  demonstrat- 
ed by  slitting  open  either  the  lateral  or  the  superior  longitudinal 
sinus,  when  a thin  delicate  membrane,  quite  distinct  from  the  fib- 
rous appearance  of  the  dura  mater will  be  found  to  line  the  inte- , 
rior  of  these  canals. 

The  inner  surface  of  many  veins  presents  membranous  folds  pro- 
jecting obliquely  into  the  cavity  of  the  vessel.  These  folds,  which, 
from  their  mechanical  office,  have  been  named  valves.,  (yalvulce^) 
are  parabolic  in  shape,  have  two  margins, — an  attached  and  free, 
and  two  surfaces,  a concave  turned  to  the  cardiac  end  of  the  vein, 
and  a convex  turned  in  the  opposite  direction.  The  attached  mar- 
gin is  not  straight,  as  may  be  imagined,  but  circular,  and  adheres 
to  the  inner  surface  of  the  vessel.  The  free  margin  resembles  in 
shape  an  oblong  parabola ; and  the  direction  of  the  valve  is  such, 
that  a force  applied  to  its  convex  surface  would  urge  it  more  closely 
to  the  vein,  whereas  a force  applied  to  the  concave  surface  would 


VEIN,  VENOUS  TISSUE. 


117 


either  obliterate  the  circular  area  of  the  vessel,  tear  the  valve  from 
the  vein,  or  otherwise  meet  with  resistance. 

The  size  of  the  valves  is  variable.  In  some  instances  they  are 
sufficiently  large  to  fill  the  canal  of  the  vessel,  and  in  others  they 
are  too  small  to  produce  this  effect.  The  obliteration  of  the  cir- 
cular area  of  the  vessel  is  most  perfect  when  there  are  two  or  three 
at  the  same  point.  Bichat  ascribed  the  variable  state  of  this  qua- 
lity to  the  dilated  or  contracted  condition  of  the  veins  at  the  mo- 
ment of  death.  This,  however,  is  denied  by  Magendie. 

In  structure  these  valvular  or  parabolic  folds  are  said  to  consist 
of  a doubling,  or  two-fold  layer  of  the  inner  membrane;  and  with 
this  statement  no  fact  of  which  we  are  aware  is  at  variance.  A 
hard  prominent  line,  which  generally  marks  their  attachment  of 
the  fixed  margin  to  the  vein,  is  asserted  by  Bichat  to  consist  of  the 
proper  venous  tissue,  the  fibres  of  which,  he  says,  alter  their  direc- 
tion for  this  purpose ; and  when  the  common  or  inner  membrane 
reaches  this  line,  it  doubles  or  folds  itself  {elle  se  replie)  to  form  the 
valve,  which  thus  consists  of  two  layers  of  the  inner  or  common 
membrane.  This,  however,  is  denied  by  Hunter,*  who  considers 
them  of  a tendinous  nature,  and  by  Gordon,  who  made  several  un- 
successful attempts  to  split  these  two  layers.f 

Valves  are  not  uniformly  present  in  all  veins.  They  are  found. 
Is?,  In  the  following  branches  of  the  superior  great  vein ; — the  in- 
ternal jugular,  the  azygos,  the  facial  veins,  those  of  the  arms,  &c. 
2d,  In  the  following  branches  of  the  inferior  great  vein ; the  divi- 
sions of  the  posterior  iliac,  of  the  femoral,  tibial,  internal  and  ex- 
ternal saphena,  and  in  the  spermatic  veins  of  the  male. 

They  are  wanting  in  the  trunk  of  the  inferior  great  vein  (cava 
inferior,)  in  the  renal,  mesenteric,  and  other  abdominal  veins,  in 
the  portal  vein,  in  the  cerebral  sinuses,  in  the  veins  of  the  brain 
and  spinal  chord,  in  the  veins  of  the  heart,  of  the  womb  generally, 
and  of  the  ovaries,  and  perhaps  in  all  other  veins  less  than  a line 
in  diameter.j;  In  the  cerebral  sinuses  the  transverse  chords  are 
supposed  to  supply  their  place. 

In  situation  the  valves  vary  considerably.  In  general  they  are 
found  in  those  parts  of  venous  canals  at  which  a small  vein  opens  into 
a larger.  But  even  from  this  arrangement  there  are  deviations. 
The  only  valve  which  is  definite  and  invariable  in  its  situation  is 

* X.  Of  Veins,  p.  182. 

+ Haller,  Lib.  ii.  sect.  ii. 


t Anatomy,  pp.  66,  67. 


118 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  Eustachian,  {valvula  Eustachiana^  valvula  nobilis^')  which  is  al- 
ways placed  at  the  cardiac  end  or  beginning  of  the  inferior  cavuy 
where  that  vessel  is  attached  to  the  sinus  of  the  right  auricle. 
Shaped  in  general  like  a crescent,  the  attached  margin  of  which  is 
the  arch  of  a large  circle,  and  the  free  that  of  a small  one,  it  pro- 
ceeds from  the  left  extremity  of  the  sinus  downwards,  forwards, 
and  towards  the  left  side,  where  it  is  insensibly  lost  on  the  mem- 
brane of  the  auricular  septum.  At  its  lower  end  it  generally 
covers  the  orifice  of  the  large  coronary  vein.  This  membranous 
production  is  always  larger,  more  perfect,  and  more  distinct  in  the 
foetus,  and  in  the  infant,  than  in  the  adult.  In  the  latter  it  is  al- 
most always  reticulated ; and  sometimes  the  only  vestige  of  its  ex- 
istence is  a thin  chord  or  two  representing  its  anterior  margin.  I 
have  seen  it  reticulated  even  at  the  age  of  sixteen  or  seventeen, 
and  almost  destroyed  beyond  thirty.  Haller  was  much  perplexed 
to  account  for  the  use  of  this  membranous  fold.*  The  conjecture 
of  Bichat,  that  it  is  connected  with  some  purpose  in  the  foetal  cir- 
culation, is  entitled  to  regard. 

Dr  Gordon  has  mentioned  a third  partial  substance,  which  is 
occasionally  found  in  local  patches  at  various  parts  of  veins.  This, 
which  I believe  to  be  accidental,  or  not  connected  with  healthy 
structure,  is,  I suppose,  the  following.  Where  the  veins  unite 
to  form  a single  trunk  at  the  point  of  union,  there  is  often  seen 
extending  from  it  into  the  trunk  a reddish  coloured  matter  of 
a triangular  shape  with  the  apex  turned  toward  and  into  the 

trunk.  This  seems  void 
j of  organization,  and  it 
appears  to  me  a deposit 
from  the  blood  exactly  at  the  point  where  the  current  is  least  forci- 
ble, upon  the  same  principle  as  that  on  which  we  observe  banks  of 
silt,  gravel,  and  sand  accumulated  under  the  sterlings  of  a bridge. 

Besides  the  cellular  or  filamentous  envelope,  veins  receive  ca- 
pillary arteries,  to  which  there  are  corresponding  veins.  The  ar- 
teries rise  from  the  nearest  small  ramifying  arteries ; and  the  cor- 
responding veins  do  not  terminate  in  the  cavity  of  the  vein  to 
which  they  belong,  but  pass  off  from  its  body,  and  join  some  others 
from  different  parts;  and  at  last  terminate  in  the  common  trunk 
some  way  higher.f  Nervous  branches,  or  rather  filaments,  are 


* Haller  de  Valvula  Eustacliii.  Extat  in  Disput.  Anatomic.  Selee.  Vol.  II.  p.  189. 
+ Hunter,  X.  Of  Veins,  p.  181. 


VEIN,  VENOUS  TISSUE. 


119 


observed  in  the  pulmonary  artery  and  great  veins  only.  Are  they 
derived  from  the  great  sympathetic,  as  is  generally  said  ? 

In  the  veins,  as  in  the  arteries,  the  anatomist  recognises  two 
extremities,  the  cardiac  or  collected,  and  the  organic  or  the  rami- 
fied. Examined  physiologically,  however,  the  terms  origin  and 
termination  are  not  of  the  same  import  as  when  applied  to  the 
arteries.  In  reference  to  the  veins,  they  become  convertible  terms ; 
and  it  is  the  usage  even  of  writers  on  anatomy  to  represent  the  veins 
as  arising  where  the  arteries  terminate,  and  terminating  at  the 
organ  from  which  the  latter  arise.  Tliis  distinction  must  be  kept 
in  view  in  the  following  observations. 

The  cardiac  extremity  or  termination  of  the  veins  is  so  well  known 
as  to  render  any  minute  explanation  unnecessary. 

The  organic  extremity  or  origin  of  the  venous  system  is  more 
obscure  and  difficult  to  be  understood.  It  is  indeed  impossible  to 
trace  the  origin  of  the  small  venous  vessels,  unless  in  the  manner 
in  which  Leuenhoek,*  William  Cowper,f  Henry  Baker,!  Haller  and 
Spallanzani,§  did  in  their  observations  on  the  transparent  parts  of 
animals  in  general  cold-blooded.  Erom  the  experiments  of  these 
observers,  we  know  that  a very  small  vessel,  evidently  tending  and 
conveying  blood  toioards  a larger,  connected  with  a venous  branch, 
may  be  seen  passing  directly  from  a similar  small  vessel,  as  evi- 
dently conveying  blood  from  a larger,  which  is  connected  with  the 
arterial  system.  All  that  we  know  from  this,  however,  is,  that  a 
vein  containing  red  blood  may  rise  from  an  artery  conveying  red 
blood.  This  is  matter  of  pure  observation,  and  all  beyond  is  little 
more  than  conjectural. 

Haller,  indeed,  admits  origins  of  veins  as  manifold  as  the  termi- 
nations of  the  arterial  system,  a view  in  which  he  has  been  followed 
by  almost  all  subsequent  authors ; and  Bichat  states  it  as  a leading 
proposition,  that  the  veins  arise  from  the  general  capillary  system. 
Neither  conclusion  is  founded  on  strict  observation  ; and  while  that 
of  the  former  physiologist  is  derived  chiefly  from  uncertain  facts 

* Arcana  Naturae  Detect.  Opera  Omnia,  Tom.  II.  p.  160,  168. 

! Philosophical  Transactions,  No.  280,  p.  1179.  Cowper  saw  this  communication 
of  arteries  and  veins  not  only  in  cold-blooded  animals,  as  the  lizard,  tadpole,  and  fishes, 
but  in  the  omentum  of  a young  cat  and  a dog. 

J On  Microscopes,  and  the  discoveries  made  thereby.  Two  vols.  8vo.  London, 
1785. 

§ Experiments  on  the  Circulation  of  the  Blood.  By  Lazaro  Spallanzani.  Trans- 
lated by  W.  Hall.  London,  1801. 


120 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


and  loose  analogies,  the  statement  of  the  latter  is  too  hypothetical 
and  general  to  be  either  entirely  true  or  wholly  false. 

Of  one  fact  only  are  we  certain.  ■ The  blood  which  is  conveyed 
into  the  small  vessels,  and  the  substance  of  the  tissues  and  organs, 
is  brought  back  by  the  veins.  We  have  seen  that  the  only  origin, 
which  is  strictly  susceptible  of  demonstration,  is  that  of  the  red  vein 
from  the  red  artery.  The  point,  then,  to  be  ascertained  is,  whether 
colourless  veins  and  absorbent  veins  arise  from  the  several  textures, 
as  colourless  and  exhalant  arteries  terminate  in  them  ? The  pro- 
per place  for  the  further  examination  of  this  question  is  the  subse- 
quent chapter. 

I must  not  omit  to  mention,  nevertheless,  that  the  veins  have 
been  shown  to  be  connected  at  their  ramified  extremities  with  the 
lymphatics. 

When  the  veins  become  distinct  vessels,  branches,  and  trunks, 
they  become  once  more  objects  of  sensible  examination.  In  their 
course  or  transit  from  their  organic  to  their  cardiac  extremities, 
they  present  various  circumstances  which  merit  attention. 

1.  In  general,  every  artery  is  accompanied  by  a venous  tube, 
which  is  divided  in  the  same  manner,  and  furnishes  or  receives  an 
equal  number  of  branches.  Thus  the  descending  aorta  is  accom- 
panied by  the  vena  cava  inferior ; the  common  iliac  arteries  by 
common  iliac  veins ; the  anterior  iliac,  femoral,  and  popliteal,  by 
anterior  iliac,  femoral,  and  popliteal  veins.  These  veins  are  deep- 
seated,  and  are  generally  named  the  concomitant  veins,  {pence  co- 
mites vel  venae  satellites.)  In  some  situations,  an  artery  may  be  ac- 
companied, either  in  its  trunk  or  in  its  branches,  by  two  veins  of 
equal  size.  Thus,  in  general,  the  brachial  artery,  and  its  branches 
the  radial  and  ulnar,  are  each  accompanied  by  two  veins.  The 
only  situations  in  which  the  number  of  veins  can  be  said  to  be  ex- 
actly equal  to  that  of  the  arteries,  are  in  the  stomach,  in  the  intes- 
tinal canal,  in  the  spleen,  in  the  kidneys,  in  the  testicles,  and  in 
the  ovaries. 

2.  In  the  extremities  and  in  the  external  regions  of  the  trunk 
we  find,  in  addition  to  the  concomitant  veins,  an  external  layer  of 
venous  tubes  immediately  beneath  the  skin,  {vence  suiter  cutem  dis- 
persce.,  VYmy.)  These  subcutaneous  or  superficial  veins  do  not  cor- 
respond to  any  artery ; but,  as  they  are  chiefly  destined  to  convey 
the  blood  from  the  skin  and  other  superficial  parts,  they  open  into 

the  deep-seated  veins.  Thus  in  the  case  of  the  basilic  and  cepha- 

3 


VEIN,  VENOUS  TISSUE. 


121 


lie,  two  superficial  veins  of  the  arm,  the  former,  after  passing  the 
bicipital  fascia,  forms  in  the  sheath  the  brachial  vein,  and  becoming 
the  axillary  in  the  axilla,  receives  the  latter  vessel.  In  the  same 
manner,  the  saphena,  (pXs'4/  /scccpaimg,  vena  manifesta,)  the  super- 
ficial vein  of  the  leg,  passes  through  the  falciform  process  of  the 
fascia  lata  to  join  the  femoral  vein. 

From  this  it  results  that  the  venous  canals  are  on  the  whole 
more  numerous  than  the  arterial.  In  a few  situations  only,  a single 
vein  corresponds  to  two  arteries,  as  in  the  penis,  the  clitoris,  the 
gall-bladder,  and  the  umbilical  chord.  Often  also  in  the  renal 
capsules  and  the  kidneys,  two  or  more  arteries  have  only  one  cor- 
responding vein.  In  such  circumstances  the  vein  is  always  large 
and  capacious. 

It  has  been  generally  stated  that  the  calibre  and  area  of  the  ve- 
nous tubes  are  much  larger  than  those  of  the  corresponding  arte- 
ries, and,  consequently,  that  the  capacity  of  the  venous  system  is 
much  greater  than  that  of  the  arterial.  I acknowledge  that  I know 
not  on  what  exact  evidence  the  former  of  these  propositions,  the 
only  one  with  which  the  anatomist  is  concerned,  is  made  to  rest. 
If  it  be  mere  inspection  in  the  dead  subject,  or  the  efiects  of  injec- 
tion, little  doubt  can  be  entertained  that  the  alleged  greater  calibre 
depends  chiefly  on  the  laxity  and  distensible  nature  of  the  venous 
fibre.  The  arterial  tubes  appear  small  in  consequence  of  the  ten- 
dency which  they  have  to  collapse,  or  annular  contraction,  when 
the  distending  force  has  ceased  to  operate.  The  venous  canals  ap- 
pear large  by  reason  of  their  distension  and  distensibility  during 
life,  from  the  tendency  to  accumulation  in  their  branches  in  most 
kinds  of  death,  except  that  by  hemorrhage,  and  from  a smaller  de- 
gree of  the  physical  property  of  shrinking  and  annular  contraction 
when  empty. 

When  a vascular  sheath  is  exposed  in  the  human  subject,  as  in 
the  operation  for  aneurism,  or  in  the  lower  animals  in  the  way  of 
experiment,  the  vein,  it  must  be  admitted,  generally  appears  larger 
than  the  corresponding  artery.  This,  however,  is  never  so  consi- 
derable as  it  is  represented  by  most  authors,  and  certainly  could 
by  no  means  afibrd  grounds  for  the  high  estimates  which  Keill, 
Turin,  and  other  mathematical  physiologists  have  assigned  to  the 
relative  capacity  of  the  arteries  and  veins.  It  is  also  to  be  observed 
that  something  of  this  greater  size  depends  on  the  increase  of  dila- 
tation resulting  from  removing  the  pressure  of  superincumbent 


122 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


parts.  In  young  animals,  also,  the  difference  between  the  size  of 
the  veins  and  their  corresponding  arteries  is  so  trifling  as  to  be 
scarcely  discernible.  This  would  show  that  something  is  to  be  as- 
cribed to  the  incessant  operation  of  a dilating  force  increasing  uni- 
formly with  the  duration  of  life. 

Upon  the  whole,  it  is  chiefly  on  the  ground*  of  their  larger  nu- 
merical arrangement  that  the  veins  collectively  can  be  said  to  be 
more  capacious  than  the  arteries.  On  this  subject  some  observa- 
tions of  Bichat  are  entitled  to  attention.^ 

3.  The  veins  _in  general  accompany  the  arteries.  The  venous 
trunk  placed  contiguous  to  the  arterial  in  the  same  sheath  is  di- 
vided into  branches  at  the  same  points,  and  is  distributed  into  the 
substance  of  organs  much  in  the  same  manner.  From  this  ar- 
rangement, however,  certain  deviations  are  observed  in  particular 
regions.  Thus,  in  the  brain,  neither  the  internal  carotid,  nor  the 
basilar  artery,  nor  their  large  branches,  are  accompanied  with 
veins.]  ^The  small  branches  only  have  corresponding  veins,  which, 
as  they  unite  to  form  large  ones,  pour  their  blood  into  the  venous 
canals  termed  sinuses,  the  arrangement  of  which  is  unlike  any 
other  part  of  the  venous  system.  In  the  chest  also  a different  dis- 
position of  the  venous  from  the  arterial  tubes  is  observed.  The 
vencB  cava,  though  conveying  the  blood  to  the  pulmonic  division  of 
the  heart,  as  the  aorta  conveys  it  from  it,  do  not,  however,  corre- 
spond with  the  latter  either  in  situation  or  in  dependent  branches. 
The  azygos  and  the  demiazygos  veins  in  like  manner,  which  re- 
ceive the  intercostal  veins,  have  no  concomitant  artery,  but  open 
into  the  superior  cava,  to  which  it  may  be  viewed  as  an  appendage. 
Lastly,  The  portal  vein,  which  is  formed  of  the  united  trunks  of 
the  splenic,  superior  mesenteric  and  inferior  mesenteric  veins,  cor- 
responds to  no  individual  arterial  trunk,  and  forms  of  itself  a pe- 
culiar arrangement  in  the  venous  system. 

Some  anatomists  have  dwelt  much  on  the  more  superficial  and 
less  sheltered  situation  of  the  veins  than  of  the  arteries.  Upon 
this  point  no  very  positive  inferences  can  be  established.  In  the 
extremities  the  former  are  in  general  most  superficial ; but  in  the 
interior  of  the  body,  especially  in  the  chest,  the  venous  trunks  are 
quite  as  deep-seated  as  the  arterial. 

The  course  of  the  venous  canals  is  in  general  more  rectilineal 
and  less  tortuous  than  that  of  the  arteries.  In  no  part  of  the  ve- 
* Aiiatomie  Generate,  Tome  I.  p.  378. 


VEIN,  VENOUS  TISSUE. 


123 


nous  system  is  such  an  inflection  presented  as  that  which  the  inter- 
nal carotid  makes  in  the  carotic  canal.  The  general  result  of  this 
is,  that  a set  of  venous  tubes  is  shorter  than  a corresponding  set  of 
arterial  ones.  The  trunks  also  are  less  inflected  than  the  branches. 

4.  The  mutual  communications  of  the  venous  system,  (anasto- 
moses^ inosculationes,)  are  more  numerous  and  frequent  than  those 
of  the  arterial.  1.  The  minute  veins  communicate  so  freely  as  to 
form  a perfect  net-work.  2.  In  the  twigs,  though  more  rare, 
these  communications  are  still  frequent.  3.  In  the  branches, 
though  less  numerous,  they  are  nevertheless  observed ; and  in  this 
respect  alone  the  venous  must  he  greatly  more  numerous  than  the 
arterial  inosculations,  which  are  confined  chiefly  to  the  smaller  and 
more  remote  parts  of  the  system.  These  inosculations,  indeed, 
between  the  venous  branches,  constitnte  one  of  the  most  peculiar 
and  important  characters  of  their  arrangement,  in  so  far  as  by  their 
means  the  communication  is  maintained  between  the  superficial  and 
deep-seated  vessels  of  the  system.  Thus  the  emissary  veins  are 
the  channel  of  communication  between  the  cerebral  sinuses  and 
the  temporal,  occipital,  and  other  external  veins.  The  external 
and  internal  jugulars  communicate  by  one  or  two  considerable  ves- 
sels. And  the  free  communication  between  the  basilic  and  cepha- 
lic by  the  median  veins,  that  between  them  and  the  deep  brachial 
vessel,  and  that  between  the  saphena  and  its  branches  and  the  fe- 
moral vein,  are  sufficiently  well  known.  The  application  of  these 
anatomical  facts  to  the  ready  motion  of  the  venous  blood  is  obvious. 

But  of  all  the  communications  between  the  branches  or  large 
vessels  of  the  venous  system,  the  most  important,  both  anatomical- 
ly and  physiologically,  is  that  maintained  by  means  of  the  vena 
azygos  between  the  superior  and  inferior  cava.  The  azygos  itself 
is  connected  at  its  upper  or  bronchial  extremity  with  the  superior 
caufl,  and  at  its  lower  extremity  it  is  in  some  subjects  connected 
directly  with  the  inferior  cava.,  in  others  by  means  of  thfe  right  re- 
nal vein,  and  in  most  by  the  first  lumbar  veins.  By  means  of  the 
demiazygos.,  again,  it  is  connected  with  the  left  renal  vein,  or  the 
lumbars  of  the  same  side,  and  in  some  instances  directly  with  the 
inferior  cava.  To  the  azygos  and  demiazygos,  therefore,  belong 
the  remarkable  property  of  connecting  not  only  the  venous  canals 
of  the  upper  and  lower  divisions,  hut  those  of  the  right  and  left 
halves  of  the  body. 


124 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Section  II. 

Venous  tissue  is  liable  to  inflammation,  adhesive  or  circum- 
scribed, and  spreading, — generally  suppurative,  to  varix,  to  osse- 
ous deposition,  and  to  the  formation  of  concretions. 

1.  Inflammation.  {^Phlehitis.^  Of  circumscribed  or  adhesive  in~ 
jiammation  of  veins,  a good  example  is  found  in  the  ordinary  union 
after  incised  wounds,  as  in  venesection.  In  this  case  the  lips  of  the 
wound,  if  accurately  applied  to  each  other,  adhere  sometimes  di- 
rectly by  inosculation,  in  other  instances  by  eflfusion  of  lymph, 
which  becomes  organized. 

2.  Spreading  injiammation  of  venous  tissue  is  a much  more  se- 
rious disorder,  and  appears  to  belong  essentially  to  the  inner  ve- 
nous membrane.  Rarely  spontaneous,  it  takes  place  only  after 
some  violence  offered  to  the  vein  ; but  the  degrees  of  this  may  he 
so  various,  and  even  the  kinds  so  different,  that  it  is  impossible  to 
trace  much  analogy  of  action  between  them.  Thus  it  may  occur 
after  a simple  clean  incision,  as  in  blood-letting ; after  the  appli- 
cation of  a ligature,  as  occasionally  happens  in  amputation,  in  the 
operation  for  varix,  or  in  the  umbilical  chord  after  birth ; or  in 
consequence  of  pressure,  as  sometimes  happens  after  the  use  of  a 
tourniquet.  In  either  case,  the  inflammatory  action  originating  in 
one  spot  of  the  inner  membrane,  spreads  along  its  surface,  generally 
towards  the  heart,  more  or  less  rapidly,  and  with  much  violence. 

The  pathological  effects  of  this  process  vary  according  to  its  se- 
verity and  extent.  In  general  the  tissue  of  the  affected  vein  or 
veins  is  swelled,  thickened,  and  indurated  to  such  a degree  as  make 
the  vessel  resemble  an  artery.  Much  pain  is  felt  along  the  course 
of  the  inflamed  vessel.  The  whole  limb  is  diffusely  swelled ; and 
the  skin  is  tense,  with  tenderness  of  the  surface.  Upon  examina- 
tion of  the  parts,  it  is  found  that  the  whole  subcutaneous  cellular 
and  adipose  tissue  are  filled  with  serous  fluid.  The  vein  is  found 
firm  and  hard,  sometimes  filled  with  bloody  clots.  When  laid  open, 
clots  of  blood  or  lymph  or  both  are  found  adhering  to  the  inner 
tunic,  which  is  rough  and  irregular,  and  thicker  than  usual.  In 
these  clots  are  contained  specks  of  purulent  matter.  In  other  in- 
stances, the  interior  is  filled  with  purulent  matter,  or  presents  a 
series  of  abscesses  along  the  tract  of  the  canal ; and  the  inner  tu- 
nic is  generally  removed,  the  middle  one  not  unfrequently  injured 
by  ulceration.  This  process  is  always  attended  with  great  commo- 


VEIN,  VENOUS  TISSUE. 


125 


tion  in  the  organs  of  circulation,  much  general  fever,  a brownish 
tint  of  the  complexion,  glaring,  injected,  suffused,  or  turbid  eyes, 
and  more  or  less  affection  of  the  intellectual  functions,  and  if  con- 
siderable, generally  proves  fatal. 

Inflammation  of  the  inner  venous  membrane  I have  represented 
generally  to  succeed  violence  offered  to  the  vessel ; but  what  sort 
of  violence  is  requisite  is  not  well  known.  I have  in  two  or  three 
instances  thought  I could  trace  it  to  wound,  laceration,  or  pressure 
in  the  site  of  a valve  ; but  in  others  this  could  not  be  established. 

I have  seen  the  disease  so  often  take  place  after  application  of 
the  finger  to  the  wound  in  the  vein  at  the  bend  of  the  arm,  in  the 
common  operation  of  venesection,  that  I cannot  doubt  that  it  is 
often  produced  in  this  manner.  The  perspiration  on  the  finger 
acts  like  an  irritant  poison  to  the  cut  edges  of  the  vein,  and  there- 
by causes  inflammation.  It  was  also  a very  common  accident  after 
injecting  saline  solutions  during  the  epidemic  cholera  in  1832.  In 
the  veins  of  the  womb,  after  parturition,  it  may  follow  the  forcible 
revulsion  of  the  placenta ; or  the  sinuses  being  left  open  and  patent, 
air  from  the  atmosphere,  or  from  the  decomposition  of  the  blood, 
or  the  uterus,  may  enter  these  canals  and  irritate  or  inflame  their 
coats.  In  this  organ  it  is  most  common  along  the  lateral  regions 
of  the  womb. 

The  circumstances  under  which  phlebitis  may  take  place  may  be 
enumerated  in  the  following  order. 

Is^,  After  venesection,  especially  when  the  finger  is  applied  to 
the  wound  so  as  to  touch  the  divided  edges  of  the  vein ; 2cf,  After 
amputation,  especially  when  there  is  much  fingering,  or  when  a 
ligature  is  put  on  a vein;  Zd,  After  laceration  of  a vein,  as  in 
certain  lacerated  wounds ; Ath,  After  any  venous  tube  has  been 
laid  open  by  ulceration  or  erosion,  as  in  cancer  or  ulceration  of  the 
womb ; 5th,  After  laying  open  the  uterine  veins,  as  in  child-bear- 
ing ; Qth,  After  deligation  of  a vein,  as  in  the  operation  for  varix, 
the  old  operation  for  castration,  in  which  all  the  vessels  were  tied 
in  one  mass,  and  after  operations  on  the  hemorrhoidal  veins. 

This  process  is  known  to  take  place  spontaneously  in  the  veins 
of  the  brain  and  in  those  of  the  womb.  The  latter  Dr  Clarke*  and 
Mr  Wilsonf  found  filled  with  purulent  matter  or  lymph  in  the  per- 
sons of  females  cut  off  by  puerperal  fever  ; and  in  a number  of  fatal 
cases  of  the  same  disease,  I saw  these  veins  containing  purulent 

* Practical  Essays  on  the  Management  of  Pregnancy,  p.  63,  72. 

t Transactions  of  a Society,  Vol.  III.  p.  63  and  p.  80. 


126 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


fluid.  Tonelle  found  among  222  cases  suppuration  of  the  uterine 
veins  in  90  cases.  Dr  Lee  among  45  cases  inspected  found  traces 
of  inflammation  of  the  uterine  veins  in  24.  Taking  both  together, 
we  have  among  267  cases  114  instances  of  phlebitis.  This 

is  not  quite  one-half;  but  it  is  as  near  as  may  be  three-sevenths. 

The  venous  tubes  of  the  brain  have  been  found  presenting  marks 
of  inflammation  by  Dr  Abercromby*  and  M.  Gendrin.f  I have 
found  inflammatory  products,  as  lymph  and  purulent  matter  with 
clots  of  blood,  within  the  sinuses  of  the  brain,  in  tbe  following  cir- 
cumstances. 

1.  In  certain  cases  of  inflammation  of  the  internal  ear  and  the 
petrous  portion  of  the  temporal  bone,  when  inflammatory  action 
had  spread  to  the  internal  jugular  vein  in  the  temporal ybssa. 

2.  In  certain  cases  of  gangrenous  inflammation  of  the  lungs, 
when  suppuration  takes  place  in  the  brain  ; and  when  the  agents 
of  this  process  appear  to  be  the  venous  canals  of  the  lungs  opening 
into  the  gangrenous  or  suppurating  portion.  Thus,  in  a child  of 
two  years,  in  whom  this  affection  of  the  lungs  had  taken  place,  I 
found  the  convolutions  of  the  brain  flattened,  the  longitudinal  sinus 
filled  with  lymph  and  purulent  particles  and  clots  of  blood,  and  a 
similar  state  of  the  lateral  sinuses,  and  several  of  the  small  sinuses. 

3.  In  cases  of  hypertrophy  of  the  spleen.  This  shall  be  noticed 
under  its  proper  head. 

It  appears,  therefore,  that  inflammation  of  the  inner  venous  coat 
rarely  terminates  in  albuminous  exudation  and  adhesion  ; and  it 
may  be  stated  as  a peculiar  character  of  this  tissue,  as  distinct  from 
the  inner  arterial  membrane,  that,  while  the  latter  is  almost  sure  to 
assume  the  adhesive,  the  former  is  exceedingly  prone  to  the  suppu- 
rative form  of  inflammation. 

3.  Instances,  nevertheless,  have  occurred  in  which  inflammation 
of  this  membrane  was  followed  by  deposition  of  lymph  and  union  of 
its  free  surfaces,  producing  obliteration  of  tbe  canal  of  the  vessel. 
Dr  Baillie  mentions  an  instance  of  obliteration  of  the  lower  cava, 
from  the  emulgent  veins  to  the  entrance  of  the  venae  cavae  hepaticce, 
which  he  ascribes  to  effusion  of  lymph  and  consequent  adhesion  \\ 
and  Mr  Wilson  records  a similar  case  in  which  about  four  ounces 
of  well-formed  purulent  fluid  were  found  in  the  vena  cava  imme- 

* Medical  and  Surgical  Journal,  Vol.  XVIII. 

•f-  Revue  Medicale,  Avril  1826. 

J Transactions  of  a Society  for  the  Improvement  of  Medical  and  Chirurgical  Know- 
ledge, Vol.  I.  Art.  viii.  p.  133. 


VEIN,  VENOUS  TISSUE. 


127 


diately  below  the  liver,  and  a considerable  quantity  of  coagulated 
lymph  below  the  entrance  of  the  three  large  hepatic  veins,  (vencB 
cavcB  hepaticcB,)  which  at  once  united  the  opposite  sides  of  the  ves- 
sel, and  prevented  this  fluid  from  proceeding  to  the  heart.*  Simi- 
lar examples  of  obliteration  are  recorded  by  Haller,  Morgagni,  and 
by  Hodgson,!  and  Breschet.  In  the  College  Museum  collection 
there  is  a preparation  of  a case  in  which  the  right  vena  innominnta 
was  filled  with  a solid  plug  of  fibrin  or  albuminous  matter,  in  con- 
sequence of  a tyromatous  tumour  compressing  the  vessel  below,  at 
its  junction  with  the  left  vena  innominata  and  vena  cava,  and  in 
which  the  left  innominata  was  very  much  contracted  at  its  lower 
end.  The  pressure  of  the  tumour  in  this  case  had  interrupted  the 
current  of  blood  to  the  heart,  and  contracted  the  channel  of  the 
vein ; and  in  consequence  blood  had  been  coagulated  and  attached 
to  the  walls  of  the  vessel,  and  so  obstructed  the  interior  of  the  vein. 

In  1841,  a man  under  my  care  in  the  hospital,  with  obstinate 
ascites  and  indications  of  liver  disease,  had  undergone  the  operation 
of  paracentesis  twice  with  relief,  when  no  benefit  was  produced  by  in- 
ternal medicines. 

About  twelve  days  after  the  performance  of  the  second  opera- 
tion, the  water  was  again  accumulating,  and  he  died.  Upon  in- 
specting the  body  after  death,  I found  the  vena  porta  in  the  liver 
completely  obstructed,  being  contracted  and  filled  with  lymph,  and 
the  lymph  extending  into  the  splenic  and  mesenteric  veins.  The 
lymph  was  small  in  quantity,  and  the  trunks  of  the  vessels  were 
evidently  diminished  in  size.  The  liver  was  reduced  to  about  one- 
fourth  of  its  usual  size,  the  whole  right  lobe  almost  had  become 
shrunk  into  a small  portion,  while  the  organ  was  represented  by  a 
small  left  lobe. 

A case  of  obliteration  of  the  vena  cava  is  recorded  by  M.  Gely 
in  Gazette  Medicale,  7th  November  1840. 

In  other  instances,  when  inflammation  in  the  vein  of  an  extremity 
takes  place,  causing  permanent  obstruction,  it  produces  not  only 
swelling  of  that  extremity,  but  deposits  of  lymph  in  the  veins,  in 
the  pulmonary  artery,  and  in  the  vessels  of  the  lungs.  Thus  I 
have  seen  inflammation  of  the  femoral  vein  with  lymphy  deposit 
within  the  vessel,  followed  after  some  time  by  the  deposit  of  similar 
lymph  and  blood  in  clots  in  the  branches  of  the  pulmonary  artery 
and  in  various  parts  of  the  lungs. 

■*  Transactions,  &c.  Vol.  III.  Art.  vi.  p.  63. 

i"  Treatise,  p.  10.  sect.  3. 


128 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


All  these  phenomena,  which  may  be  called  the  secondary  etFects 
of  phlebitis^  arise  from  the  inflammatory  deposits,  viz.  lymph  and 
purulent  matter,  being  taken  into  the  veins  and  circulated  along 
these  vessels ; and  sometimes  from  purulent  matter  being  carried 
by  the  veins  directly  to  the  pleura,  the  veins  of  the  lungs,  or  the 
synovial  membrane,  or  the  cellular  membrane. 

4.  Purulent  matter  and  lymph  may  be  found  within  the  veins, 
and  prove  a cause  of  death.  Thus  in  a case  of  hypertrophy  of  the 
spleen  I found  purulent  matter  and  lymph  in  the  sinuses  of  the 
brain,  and  the  veins  of  the  chest  and  abdomen.*  In  such  cases  the 
deposit  is  not  preceded  by  inflammation. 

It  is  easy  to  perceive  how  the  pressure  of  tumours  may  cause 
obliteration  of  these  vessels.  When  any  venous  tube,  under  such 
circumstances,  becomes  impervious,  the  collateral  communications 
afford  channels  for  continuing  the  motion  of  the  blood. 

5.  Secondary  effects  of  Phlebitis.  Inflammation  of  veins,  though 
usually  and  ordinarily  a fatal  disease,  is  neither  necessarily  so,  nor 
always.  But  when  it  has  terminated,  as  it  commonly  does,  in 
the  formation  of  purulent  matter,  it  occasionally  gives  rise  to 
a train  of  very  remarkable  and  dangerous  phenomena.  This  I 
shall  describe  in  two  forms,  as  it  most  usually  presents  itself. 

In  the  ordinary  case  of  inflammation  of  the  vein  taking  place 
after  venesection,  when  the  patient  survives  the  immediate  eflfects, 
lymph  having  been  eflfused,  and  caused  obliteration  of  part  of  the 
vessel,  purulent  matter  is  effused  at  the  same  time  ; or  rather  the 
effusion  is  a sort  of  sero-albuminous  matter,  the  thicker  portion  of 
which  is  the  medium  of  partial  and  local  adhesion,  while  the  more 
liquid  forms  purulent  fluid.  The  latter  is  taken  into  the  circula- 
tion ; and  the  original  febrile  symptoms  assume  the  characters  of 
hectic.  Soon  after  the  patient  has  difficult  and  laborious  breath- 
ing, with  pain  in  some  part  of  the  chest  or  side,  and  purulent 
matter  is  formed  within  the  pleura.  Or  another  result  may  ensue. 
With  the  symptoms  of  great  disorder  in  the  organs  of  respiration, 
as  rapid  laborious  breathing  and  cough,  without  expectoration,  the 
symptoms  of  hectic  fever  continue ; and  after  two  or  three  weeks, 
the  patient  being  much  emaciated  and  feeble,  dies.  On  inspection 
of  the  body,  the  lungs,  when  divided,  present  numerous  abscesses, 

* Case  of  Disease  of  the  Spleen,  in  which  death  took  place  in  consequence  of  the 
presence  of  purulent  matter  in  the  blood.  By  David  Craigie,  M.  D.  &c.  Edinburgh 
Medical  and  Surgical  Journal,  Vol.  LXIV.  p.  400. 


VEIN,  VENOUS  TISSUE. 


129 


not  larger  than  peas.  When  these  are  examined,  they  are  found 
to  be  not  abscesses,  but  the  veins  of  the  lungs  filled  with  purulent 
matter.  The  veins  of  the  arm  are  at  the  same  time  thickened  in 
their  walls,  and  contain  lymph  and  purulent  matter.  These  ap- 
pearances I observed  in  the  body  of  a young  man,  on  whom  vene- 
section had  been  performed  three  weeks  previously  for  the  removal 
of  symptoms  of  peritonitis.  Similar  phenomena  were  seen  by  Vel- 
peau in  a case  of  amputation. 

In  other  instances  the  intermuscular  cellular  tissue,  either  of  an 
arm  or  a leg  is  attacked ; and  purulent  collections  more  or  less  ex- 
tensive are  deposited  in  them.  At  the  same  time  one  or  more  of 
the  joints,  as  the  shoulder -joint  or  the  knee-joint,  may  be  attacked 
with  acute  pain,  aggravated  by  motion  and  pressure,  swelling  and 
heat ; and  in  no  long  time  it  is  observed  that  fluid  has  been  form- 
ed within  the  joint.  This  is  most  commonly  purulent,  from  in- 
flammation of  the  synovial  membrane.  After  it  has  taken  place, 
the  synovial  membrane  is  removed  by  ulceration ; the  cai'tilages 
are  partially  or  entirely  destroyed  in  the  same  manner ; and  either 
the  joint  becomes  ankylosed  by  the  adhesion  of  the  lymphy  effusion, 
or  the  patient  is  destroyed  by  the  long-continued  severe  irritation 
on  the  constitution. 

When  the  veins  of  the  womb  have  been  the  seat  of  inflammation, 
if  the  morbid  action  do  not  terminate  fatally,  it  is  occasionally  fol- 
lowed by  the  same  train  of  phenomena  as  have  been  now  enume- 
rated ; — purulent  deposits  within  the  pleura,  purulent  deposits  in  the 
intermuscular  cellular  tissue  of  the  extremities,  and  purulent  de- 
posits within  the  joints,  most  usually  the  knee-joint.  The  most  fa- 
vourable case  is  that  of  purulent  deposits  among  the  muscles  of  the 
extremities,  especially  the  leg.  Yet  here,  often  in  the  process  of 
healing,  adhesions  between  the  muscles  take  place,  and  lameness  is 
the  result. 

6.  Varix.  This  consists  in  permanent  dilatation  of  the  venous 
coats  beyond  their  natural  capacity.  It  is  in  general,  if  excessive, 
confined  to  one  spot ; but  sometimes  a whole  vein  becomes  more 
or  less  dilated  through  its  entire  course.  At  the  same  time  it  be- 
comes so  tortuous,  that  this  may  be  received  as  one  of  the  physical 
characters  of  varicose  veins.  W e possess  no  very  precise  facts  on 
the  exact  change  which  takes  place  in  the  venous  tunics,  whether 
it  be  mere  dilatation  or  injury  of  some  kind,  and  rupture  of  the 
proper  venous  coats.  By  Meckel  it  is  regarded  as  simple  dilatation 

I 


130 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


without  injury  of  texture.  When  one  part  of  a vein  is  dilated  into 
a distinct  sac,  I believe  the  inner  coat  is  generally  rent.  In  some 
cases  of  varix  one  or  more  valves  are  lacerated,  or  detached  from 
the  inner  membrane.  In  others  varix  has  followed  a rent  or  lace- 
rated w'ound  of  the  outer  venous  tunic,  or  a cutaneous  ulcer  affect- 
ing that  tunic. 

Varix  occurs  especially  in  the  veins  of  the  lower  extremities,  for 
instance  in  the  trunk  or  branches  of  the  saphena.  It  is  common  in 
those  of  the  spermatic  chord,  in  which  it  is  distinguished  by  the 
name  of  varico-cele^  and  not  unfrequent  in  the  veins  of  the  rectum, 
where  it  causes  one  variety  of  hemorrhoidal  tumours.  In  the  up- 
per extremities  it  is  rare,  one  case  only  by  Petit  being  recorded. 
I have  seen,  nevertheless,  a varicose  tumour  of  the  posterior  ulnar 
vein  on  the  back  of  the  hand,  which  disappeared  under  the  use  of 
pressure,  continued  for  six  or  seven  months. 

Of  the  internal  veins  the  vena  azygos  and  subclavian  have  been 
found  varicose.  (Morgagni,  Portal,  Baillie.)  When  a cluster  of 
subcutaneous  veins  becomes  varicose,  they  generally  give  rise  to 
much  pain,  swelling  and  redness  of  the  skin,  and  if  not  opposed  by 
suitable  treatment,  may  produce  cutaneous  inflammation  terminating 
in  a bad  ulcer.  ( Ulcus  varicosum.)  The  same  process  nearly  may 
result  from  the  inflammation  round  a single  varicose  trunk.  Varix 
sometimes  terminates  in  laceration  or  rupture ; and  if  the  vein  be 
large  and  not  covered  by  the  skin,  the  hemorrhage  may  be  fatal. 
(Laurentius,  Nebel,  Bonet.)  Varix  of  the  vena  azygos  terminating 
in  rupture  and  fatal  hemorrhage  was  seen  by  Manfredi.* 

Ossification.  Calcareous  or  osseous  matter  is  very  rarely  depo- 
sited in  venous  tissue.  Instances  of  this,  however,  are  recorded, 
(Morgagni,  Baillie,  Hodgson. )f 

Loose  stony  concretions  have  been  found  in  the  cavity  of  veins, 
which  in  such  circumstances  are  generally  dilated.  These  concre- 
tions do  not  appear  to  be  formed  and  deposited  in  the  venous  tissue, 
but,  according  to  Hodgson,  are  more  likely  to  have  been  produced 
outside  by  some  contiguous  tissue,  and  to  liave  found  their  way  in- 
to the  venous  tube  by  progressive  absorption.  Is  it  not  possible 
that  they  are  the  result  of  temporary  retardation  or  stagnation  of 
a portion  of  blood  around  which,  as  a nucleus,  calcareous  matter 
had  been  deposited  ? They  have  not  been  chemically  examined ; 
but  it  is  said  that  they  have  no  appearance  of  any  thing  osseous. 

* Morgagni,  xxvi.  29.  -f-  Treatise,  Part  iv.  sect.  2. 


SYSTEM  OF  CAPILLARY  VESSELS,  &C. 


131 


These  concretions,  which  in  other  respects  are  very  imperfectly 
known,  have  been  termed  veinstones.  (Phlebolites.) 


CHAPTER  VIL 

SYSTEM  OF  CAPILLARY  VESSELS, — TERMINATIONS  OF  ARTERIES, — 
ORIGINS  OF  VEINS. 

Section  I. 

Though  we  can  scarcely,  with  propriety,  speak  of  the  capillary 
tissue.!  tissue  of  capillary  vessels,  we  find  it  requisite  to  intro- 

duce in  this  place  the  general  facts  of  the  anatomical  peculiarities 
of  this  important  part  of  the  human  body. 

The  term  capillary  system,  though  much  spoken  of  in  physiolo- 
gical and  pathological  writings,  is  perhaps  not  always  precisely  de- 
fined or  distinctly  understood.  According  to  Bichat  it  is  not  only 
the  common  intermediate  system  between  the  arteries  and  veins, 
but  the  origin  of  all  the  exhalant  and  excreting  vessels.*  If  we 
consider  the  modes  in  which  arteries  have  been  said  to  terminate, 
and  veins  to  take  their  origin,  we  shall  find,  that  in  this  view  of  the 
capillary  system  there  are  some  things  which  are  doubtful,  and 
some  which  are  inconsistent  with  the  rest, 

Haller,  and  most  of  the  physiological  authorities  since  his  time, 
concluded,  chiefly  from  the  phenomena  of  injections,  sometimes 
from  microscopical  observation,  and  where  these  failed,  from  the 
obscure  and  uncertain  evidence  of  analogy,  that  an  artery  traced 
to  its  last  or  minute  divisions  will  be  found  to  terminate  in  one  or 
other  of  the  following  modes.  Is^,  Either  directly  in  a red  vein  or 
veins ; 2d,  in  excreting  ducts,  as  in  the  lacrymal  and  salivary  glands, 
the  kidney,  liver,  and  pancreas,  the  female  breast,  and  the  testicle 
of  the  male ; 3d,  in  exhalants,  as  in  the  skin,  in  the  membranes  of 
cavities,  (serous  membranes,)  the  cavities  of  the  brain,  the  cham- 
bers of  the  eye,  the  filamentous  tissue,  the  adipose  cells,  the  pulmo- 
nary vesicles,  and  mucous  surfaces  and  their  follicular  glands ; 4?/«, 
in  smaller  vessels,  for  instance  lymphatics ; and,  5th,  in  the  colour- 
less artery ; (arteria  non  rubra.)] 

* Anat,  Gen.  Vol.  I.  p.  471.  Systeme  Capillaire,  Article  1. 

-j-  Elementa  Physiologise,  Lib.  i.  sect.  1.  p.  22-29. 


132 


GENEHAL  AND  PATHOLOGICAL  ANATOMY. 


A similar  application  of  the  same  facts  has  assigned  to  the  veins 
a mode  of  origin  not  unlike.  If,  therefore,  we  admit  the  definition 
given  by  Bichat,  it  follows  that  the  capillary  system  consists,  Is^, 
of  minute  arteries  communicating  with  veins ; 2d,  of  excreting 
ducts ; 3(Z,  of  exhalants ; and,  Ath,  of  minute  arteries  or  veins  con- 
taining a colourless  portion  of  the  blood.  It  is  obvious,  however, 
that  it  is  absurd  to  say  that  the  system  of  capillary  vessels  at  once 
comprehends  and  gives  origin  to  the  excretories  and  exhalants.  In 
other  respects  the  whole  of  this  theory,  for  little  of  it  is  matter  of 
strict  observation,  rests  on  very  hypothetical  grounds. 

Of  the  different  kinds  of  terminations  assigned  to  arteries,  and  of 
origins  assigned  to  veins,  one  only  admits  of  sensible  and  satisfac- 
tory demonstration.  Arteries,  when  they  have  so  much  diminished 
as  to  become  capillary,  are  seen  by  the  microscope,  in  some  instan- 
ces by  the  naked  eye,  to  pass  directly  into  corresponding  capillary 
veins,  or  to  end  abruptly  in  some  organ  or  membrane  unconnected 
with  any  other  vessel.*  It  is  likewise  certain  that  the  microscope 
shows  every  capillary  vein  to  arise  from  a capillary  artery ; and  if 
there  be  any  other  mode  of  origin,  it  has  not  yet  been  demonstra- 
ted or  established.!  Only  one  other  circumstance  requires  to  be 
taken  into  account  in  this  inquiry.  This  is,  that  the  capillary  ar- 
tery and  vein  may  contain  either  red  or  colourless  blood ; for,  ac- 
cording to  the  size  of  the  vessels,  and  the  nature  of  the  organs  or 
tissues  in  which  they  are  distributed,  the  blood  which  flows  through 
them  will  be  coloured  or  colourless.  This  view  of  the  communi- 
cation of  minute  arteries  and  veins,  which  is  perfectly  consistent 
with  the  known  facts,  will  afford  the  only  explanation  which  it  is 
possible  to  give,  of  the  singular  division  of  the  capillary  system 
which  Bichat  has  chosen. 

This  author  has  considered  the  capillary  system  under  three  ge- 
neral heads.  Is^,  In  organs  in  which  it  contains  blood  only ; for 
instance,  in  the  muscles,  the  spleen,  some  parts  of  the  mucous  mem- 
branes. 2d,  In  organs  in  which  it  contains  blood  and  other  fluids ; 
for  example,  in  bone,  cellular  tissue,  serous  membrane,  part  of  the 
fibrous  system,  the  skin,  the  vascular  parietes,  glands,  &c.  And, 
Zd,  In  organs  in  which  it  contains  no  blood,  the  instances  of  which 
are,  tendon,  cartilage,  ligament,  hair,  &c. 

Now,  it  is  of  little  consequence  to  say  that  the  tissues  of  the  two 
last  divisions  contain  other  fluids  thaa  blood,  when  we  are  also  told 

t Ib.  p.  62. 


Gordon,  p.  56. 


SYSTEM  OF  CAPILLARY  VESSELS,  &C. 


133 


that  the  phenomena  of  injections,  which  prove  that  their  capillaries 
communicate  directly  with  arteries  conveying  red  blood,  the  effect 
of  irritating  applications  mechanical  or  chemical,  and  the  phenomena 
of  acute  or  chronic  inflammation,  show  that  they  may  convey  or 
receive  red  blood.  The  conclusion  of  this  in  common  language  is, 
that  the  capillary  arteries  and  veins  of  the  second  order  of  tissues 
do  not  all  contain  red  blood,  but  that  many  of  them  contain  a co- 
lourless part  of  that  fluid ; and  that  all  the  capillary  arteries  and 
veins  of  the  third  order  of  tissues  convey  in  the  natural  state  co- 
lourless blood  only.  What,  then,  is  the  precise  idea  which  ought 
to  be  formed  of  the  intermediate  system  which  Bichat  conceived  to 
exist  between  the  minute  arteries  and  veins,  or  what  have  been 
termed  the  venous  radicula? 

It  appears  that  the  present  state  of  facts  will  admit  of  nothing 
more  to  constitute  this  capillary  system  than  those  minute  vessels, 
whether  conveying  coloured  or  colourless  blood,  in  which  inspec- 
tion, microscopic  observation,  and  injections  show  that  arterial 
branches  at  once  terminate,  and  minute  veins  {i-adicul(B  venose) 
have  their  origin.  It  is  clear  that,  physiologically  speaking,  these 
vessels  can  neither  be  regarded  as  arteries  nor  as  veins  strictly ; 
for  the  characters  on  which  this  distinction  is  founded  are  neces- 
sarily lost  or  obliterated  in  this  system  of  vessels.  There  is  no  pre- 
cise point  at  which  the  arterial  tissue  or  structure  can  be  said  to 
terminate,  and  none  at  which  the  venous  structure  can  be  said  to 
commence.  Microscopic  observation  shows  merely  a minute  and 
endless  network  of  interlacing  and  communicating  vessels,  in 
which  the  blood  moves  with  great  velocity.  And  the  vessels  are 
too  small  to  allow  their  structure  to  be  correctly  examined.  If, 
however,  we  adopt  the  doctrines  of  Bichat  with  regard  to  the 
inner  arterial  and  venous  tunics  forming  the  ultimate  tube  of 
small  arteries  and  small  veins,  we  must  conclude  that  the  arte- 
rial membrane  is  lost  in  the  venous,  and  that  the  common  mem- 
brane of  red  blood  is  identified  with  the  common  membrane  of 
dark  or  modena  blood.  In  this  conclusion  there  is  nothing  either 
absurd  or  improbable,  and,  though  not  founded  on  actual  obser- 
vation, it  is  greatly  more  natural  than  many  similar  ideas  which 
have  been  formed  on  the  nature  of  this  system  of  vessels.  It 
may  be  added  that  it  is  not  at  variance  with  w'hat  is  observed  in 
these  vessels  in  the  living  body.  It  is  found  that  the  blood  in  a 


134 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


minute  artery  is  not  of  the  bright  red  colour  which  it  possesses  in 
the  trunk  and  large  branch  from  which  the  minute  artery  derives 
its  blood,  but  is  gradually  acquiring  the  dark  hue  which  belongs 
to  the  blood  of  the  venous  branches  and  trunks. 

By  some,  again,  this  direct  communication  of  minute  arteries 
and  veins  is  denied.  Thus,  according  to  Doellinger,  the  arteries 
at  their  last  ramifications  are  devoid  of  proper  membranous  walls  ; 
the  blood  moves  in  immediate  contact  with  the  solid  matter  of  the 
body,  which  is  in  truth  the  fundamental  or  penetrating  filamentous 
tissue ; and  from  this  it  passes  into  the  venous  tubes  and  lym- 
phatics, which  also  arise  from  this  substance. 

According  to  Wilbrand,  again,  who  equally  denies  this  direct 
communication  of  arteries  and  veins,  all  the  blood  is  converted 
into  organic  fibres  and  secretions ; and  these  organic  fibres  becom- 
ing gradually  fluid  are  converted  into  blood  and  lymph,  which  con- 
tinue the  circulation. 

These  notions  are  too  fanciful  and  too  incapable  of  demonstra- 
tion to  become  the  object  of  serious  attention  to  the  anatomist.  It 
is  of  little  moment  whether  the  vessels  in  the  ultimate  ramifications 
possess  tunics  or  not.  When  they  cease  to  possess  tunics  they 
cease  to  be  vessels ; and  to  carry  observation  beyond  this  point  is 
either  impracticable  or  useless.  In  other  respects  the  investigation 
of  this  point  belongs  to  the  subject  of  the  exhalant  vessels. 

This  idea  is,  however,  adopted  by  Wedemeyer,  who  founds  it 
chiefly  on  the  fact,  that  he  could  not  detect  by  the  microscope  any 
membrane  interposed  between  the  parenchyma  of  the  tissues  and 
the  blood  moving  in  the  minuter  capillaries,  or  rather  furrows  in 
which  it  is  seen.  It  must  be  allowed  that  this  idea  receives  some 
confirmation  from  a fact  to  be  afterwards  noticed,  that  during  in- 
flammation, new  vessels  are  observed  by  the  microscope  to  be  formed 
in  inflamed  parts. 

Bichat  has  described  two  great  capillary  systems  in  the  human 
body.  Is^,  The  general  one,  or  that  which  consists  of  the  minute 
terminations  of  the  aortic  divisions,  and  the  origins  of  the  superior 
and  inferior  great  veins;  and,  2d,  The  pulmonary  capillary  system, 
or  that  which  consists  of  the  minute  terminations  of  the  pulmonary 
artery,  and  the  origins  of  the  pulmonary  veins.  It  is  evident,  that 
the  manner  in  which  the  first  of  these  systems  is  here  repre- 
sented, communicates  a very  incorrect  idea  of  its  true  character; 


SYSTEM  OF  CAPILLARY  VESSELS,  &C. 


135 


and  that  there  is  actually  an  individual  capillary  system,  not  only 
for  every  organ,  but  in  some  instances  for  every  tissue.  The  brain 
possesses  an  individual  capillary  system  ; and  that  of  the  mem- 
branes is  evidently  distinct  from  that  belonging  to  the  organ  itself. 
The  heart  and  the  kidneys  possess  each  an  individual  capillaiy 
system;  and  the  liver  may  be  said  to  have  two, — one  formed  by  the 
communication  of  the  hepatic  artery  and  veins,  and  another  con- 
sisting of  the  divisions  of  the  portal  vein,  with  the  branches  of  the 
hepatic  hollow  vein,  (Vena  cava  hepatica.) 

The  organic  properties  of  the  capillary  vessels  are  as  little  known 
as  their  structure.  Many  physiological  and  pathological  writers, 
especially  experimentalists,  have  ascribed  to  them  a power  which 
has  at  different  times  been  called  muscular,  tonic,  irritable,  con- 
tractile; and  have  asserted  that,  because  the  larger  arteries  are 
provided  with  a fibrous  membrane,  which  they  have  called  muscu- 
lar, and  to  which  they  have  ascribed  irritability,  or  the  power  of 
contraction  when  stimulated,  their  minute  or  capillary  termina 
tions  must  have  the  same  property.  This  conclusion  is  completely 
unfounded  for  two  reasons.  Is^,  I have  already  shown  that  the 
proper  arterial  tunic  is  not  muscular  in  structure,  and,  according 
to  the  best  experiments,  possesses  no  property  of  contraction  when 
stimulated,  2d,  Although  it  be  admitted  that  the  proper  arterial 
tissue  is  muscular  and  irritable,  it  is  quite  certain  that  observation 
has  not  hitherto  shown  that  this  tunic  can  be  recoo'nised  in  arteries 

O 

smaller  than  a line  in  diameter ; and  it  is  certain  that  in  the  capil- 
laries, properly  so  called,  that  is,  in  vessels  which  partake  of  the 
nature  of  artery  and  vein,  no  such  structure  has  yet  been  observed. 

It  is  not  impi’obable,  however,  that  the  capillaries  possess  certain 
organic  or  vital  properties ; but  all  that  has  been  taught  on  this 
subject  is  either  hypothetical,  or  derived  from  an  insufficient  and 
imperfect  collection  of  facts.  It  is  certain  that  the  blood  which 
moves  through  them  is  beyond  the  direct  influence  of  the  action  of 
the  heart,  and  can  be  affected  by  this  only  so  far  as  it  keeps  the 
larger  vessels  constantly  distended  with  a column  of  blood  which 
cannot  retrograde,  and  must  therefore  move  forward  in  the  only 
direction  left  to  it.  It  has  been  therefore  argued  that  the  capil- 
laries must  have  an  inherent  powder  of  contraction  by  which  this 
motion  is  favoured.  Is  it  not  sufficient  to  say  that  they  act  merely 
as  resisting  canals,  to  prevent  their  contents  from  escaping,  and  to 
minister  to  the  various  tissues  and  organs  those  supplies  of  blood 
which  the  several  processes  of  nutrition,  secretion,  &c,  require  ? 


136 


GENERAL  AND  PATHOLOGICAL  ANATOIIY. 


The  experiments  of  Wedemeyer  and  Dutrochet  show  that  the 
capillary  vessels  are  the  seat  of  an  action  of  intro-pulsion  and  ex- 
tro-pulsion  of  fluids,  (endosrnosis  and  exosmosis,')  or  a force  by  which 
fluids  may  be  impelled  inwardly  into  them,  or  in  the  opposite  di- 
rection without  them. 

The  effects  which  the  application  of  mechanical  Irritants,  or 
chemical  substances,  as  alcohol,  acids,  and  alkalis,  produced  in 
the  experiments  of  Hunter,  Wilson  Philip,  Thomson,  and  Has- 
tings, have  been  supposed  to  demonstrate  the  irritable 'nature  of 
the  capillary  vessels.  The  conclusion  is  illegitimate,  in  so  far  as 
the  results  of  these  experiments  are  open  to  several  sources  of 
fallacy.  In  some  instances  these  effects  are  to  be  ascribed  to  In- 
cipient inflammation,  in  others  to  shrivelling  of  the  capillary  struc- 
ture, or  crispation  by  chemical  action,  in  others  to  actual  coagula- 
tion of  the  blood  of  the  capillaries ; but  none  of  them  prove  satis- 
factorily or  precisely  any  peculiar  properties  in  the  vessels  of  which 
the  capillary  system  is  composed. 

Section  H. 

The  morbid  deviations  incident  to  the  system  of  capillary  vessels 
are  of  the  utmost  importance.  As  they  are  the  main  agents  of 
most  of  the  healthy  processes  of  the  animal  body,  so  there  are  few 
morbid  states,  in  which  their  operation  is  not  primary,  or  in  which 
they  do  not  more  or  less  partake.  To  enumerate  these  would  form 
a long  nosological  list,  since  the  diseases  of  every  tissue  depend 
chiefly,  if  not  entirely,  on  its  eapillary  system.  It  will  be  sufficient 
to  consider  the  influence  of  the  capillary  vessels  as  an  individual  or 
isolated  organic  system  in  the  production  of  morbid  action. 

1.  Inflammation.  The  capillary  vessels  are  believed  to  be  the 
exclusive  seat  of  the  morbid  process  termed  injlammatmi.  No  tis- 
sue, or  no  substance,  rather,  destitute  of  capillaries,  is  believed  sus- 
ceptible of  this  process;  and  its  frequency  and  violence  are  justly 
estimated  in  proportion  to  the  number  of  capillaries  with  which  the 
tissue  is  supplied.  Hair,  nail,  enamel  of  the  tooth,  and  cuticle,  do 
not  undergo  inflammation  ; and  their  morbid  states  are  to  be  as- 
cribed to  disorder  of  the  textures  on  which  their  existence  and  nu- 
trition depend.  Filamentous  tissue,  on  the  other  hand,  mucous 
and  serous  membrane,  and  the  substance  of  such  organs  as  the 
lung,  liver,  &c.  are  very  liable  to  various  forms  of  inflammatory  ac- 
tion, which  is  generally  proportional  to  the  predominance  of  red 


SYSTEM  OF  CAPILLAEY  VESSELS,  &C. 


137 


capillaries  in  the  substance  of  each.  Bichat  has  justly  observed 
that  inflammation  is  very  frequent  in  the  cutaneous,  mucous,  se- 
rous, and  filamentous  tissues,  which  injection  and  microscopic  ob- 
servation show  to  abound  in  capillary  vessels,  but  rare  in  bone, 
cartilage,  and  the  fibrous  tissues  in  vvhich  there  are  few  capillaries, 
or  where  the  irritable  or  inflammatory  susceptibility,  (la  sensibilite 
organique,)  is  more  moderate.  It  is  difficult  to  explain  the  infre- 
quency of  inflammation  in  muscular  tissue  without  having  recourse 
to  this  last  property,  which  this  author  ascribes  to  the  capillary 
vessels.  Its  sensibility  to  the  operation  of  a stimulus  is  great.  Its 
susceptibility  of  inflammatory  action  is  very  small. 

The  change  which  takes  place  in  the  capillary  vessels  in  the  state 
of  inflammation  has  given  rise  to  much  speculation,  research,  and 
experiment. 

But  it  may  be  doubted  whether  the  questions  which  have  been 
agitated  on  this  subject  can  yet  be  regarded  as  decided.  On  one 
point  only  is  there  any  thing  like  agreement  in  the  various  opinions 
delivered.  It  appears  to  be  now  the  general  belief,  that  during 
the  process  of  inflammation  the  capillary  vessels  of  the  part  are 
dilated,  and  contain  more  blood  than  in  the  healthy  state.  (Cul- 
len, Hunter,  Vacca,  and  many  other  authors.)  On  the  cause  of 
this  dilatation,  however,  the  sentiments  of  pathologists  are  as  much 
at  variance  as  ever ; and  not  only  are  the  results  of  experiments 
made  to  determine  the  circumstances  on  which  this  distended  state 
of  the  capillaries  depends,  variable  and  sometimes  contradictory, 
but  the  conclusions  to  which  they  have  led  are  very  opposite. 
One  opinion  is,  that  the  dilatation  depends  on  increased  action ; 
according  to  the  other,  it  is  the  effect  of  a weakened  state  of  the 
capillaries. 

The  first  of  these  docti’ines,  which  in  some  form  or  other  has 
been  adopted  from  Stahl,  and  De  Gorter,  by  Dr  Cullen,  appears  to 
have  been  suggested  by  the  increased  number  of  the  arterial  pulse 
in  a given  space,  the  hardness  and  tension  of  its  beat,  the  throb- 
bing of  inflamed  parts,  and  the  violent  and  sometimes  rapid  changes 
of  structure  which  attend  inflammation.  This  has  led  to  the  con- 
clusion that  the  blood  moves  in  the  capillaries  of  such  parts  more 
rapidly,  and  with  greater  force,  (momentum^  than  in  the  healthy 
state.  (Parry.  ) With  superficial  observers  this  opinion  has  pass- 
ed current,  as  generally  consonant  with  the  phenomena  and  effects 
of  the  inflammatory  process ; and  the  pathologist  has  studied  to 


138 


GENERAL  AND  I'ATHOLOGICAL  ANATOMY. 


render  his  notions  palpable,  by  supposing,  in  the  language  of  tlie 
mathematical  physicians,  an  inoi'dinate  flow,  morbid  affiux^  or  in- 
creased determination  of  blood  to  the  inflamed  parts.  Had  this 
opinion  ever  been  subjected  to  rigid  scrutiny,  its  fallacy  must  have 
been  manifest. 

Is#,  The  fact  of  increased  determination  is  not  established.  In 
its  present  state  it  is  a mere  assumption,  2<f,  Increased  determi- 
nation is  not  necessary  to  the  production  of  the  effect.  When  the 
capillaries  of  any  part  are  unusually  loaded,  this  may  take  place 
from  the  blood  not  being  removed  with  the  same  regularity,  and  in 
the  same  proportion  in  which  it  is  conveyed,  with  the  same  facility 
as  by  supposing  an  increased  current,  3c#,  Even  admitting  the 
current  to  be  increased  through  any  set  of  capillaries,  it  is  impossi- 
ble to  discover  the  agents  of  such  a process.  It  is  cleai'  it  cannot 
be  the  heart.  And  to  suppose  the  capillaries  capable  of  this,  is 
to  ascribe  to  them  a power  which  they  have  not  been  proved,  in 
ordinary  circumstances,  to  possess. 

Against  the  hypothesis  of  increased  force  and  increased  velocity 
of  circulation,  various  arguments  may  be  urged ; and  several  of 
these  depend  on  the  circumstance,  that  this  hypothesis  also  has 
been  assumed  on  very  insufficient  grounds.  Is#,  The  increased 
number  of  the  arterial  pulse  does  not  demonstrate  that  the  blood  is 
moving  more  rapidly  than  in  the  ordinary  circumstances  of  health. 
It  merely  shows  that  the  heart  contracts  more  frequently  in  a given 
time  than  usual.  2f/,  The  increased  number,  or  strength,  or  ten- 
sion of  the  arterial  pulse  does  not  indicate  that  the  blood  is  moving 
with  greater  force,  or  that  the  arteries  through  which  it  is  moving 
are  acting  with  greater  power,  but  rather  that  the  heart  is  contract- 
ing much  more  frequently  in  order  to  overcome  some  obstacle. 
3fZ,  It  does  not  appear  that  the  increased  number  or  force  of  the 
pulse,  as  manifested  by  the  contractions  of  the  heart,  depends  on 
any  other  cause,  than  the  vital  irritation  occasioned  by  a local  sti- 
mulus of  a morbid  nature.  4#/i,  The  throbbing  of  inflamed  parts 
proves  nothing  more,  than  that  the  shock  communicated  from  the 
lieart  along  the  arterial  tubes  is  rendered  more  sensible,  first,  by 
their  dilated  and  distended  condition  ; and,  secondly,  by  the  greater 
quantity  of  matter  deposited  in  and  around  these  vessels.  (Parry.) 

On  the  other  hand,  it  appears  to  me  certain  that,  from  what  we 
see  by  the  microscope  in  the  vessels  of  cold-blooded  animals,  as 
the  frog,  fish,  &c.  the  blood  moves  most  rapidly  in  the  healthy 


SYSTEM  OF  CAPILLAEY  VESSELS,  &C. 


139 


state ; and  when  it  moves  slowly,  or  is  retarded,  and  stops  or  re- 
trogrades, as  is  occasionally  seen,  this  is  unnatural,  and  if  continu- 
ed for  any  time  constitutes  a morbid  state.  This  is  further  con- 
firmed by  the  results  of  the  experiments  made  by  Kaltenbrunner, 
who  ascertained  that  in  inflammation  and  similar  morbid  states,  the 
blood  not  only  moved  more  slowly,  but  formed  what  he  called 
stases,  or  points  of  immobility  and  stagnation. 

The  second  doctrine,  that  the  distended  or  dilated  state  of  the 
capillaries  is  to  he  ascribed  to  weakness  or  debility  in  their  coats, 
appears  to  be  more  consonant  with  the  usual  phenomena  of  the 
process,  and  with  the  effects  which  it  produces  iu  the  different  tis- 
sues. But  although  much  has  beeu  lately  done  by  IVilson  Philip, 
Hastings,  and  others,  to  determine  this  point,  it  is  still  beset  with 
some  difficulties  and  objections,  and  would  perhaps  require  some 
variation  in  the  experiments,  in  order  to  place  the  subject  in  the 
clearest  light.  This  hypothesis  first  originated  with  Vacca  Ber- 
linghieri,  and  was  supported  in  this  country  by  Lubbock,  Allen, 
Reeve,  Thomson,  Wilson  Philip,  and  subsequently  by  Hastings 
and  Black,  and  receives  some  confirmation  from  the  experiments  of 
Kaltenbrunner,  who  has  given  the  most  complete  set  of  observations 
on  this  subject.  This  author  regards  congestion  as  a preliminary 
stage  of  inflammation,  and  he  therefore  considers  in  connection  the 
phenomena  presented  by  both. 

Congestion  he  considers  as  a process  increasing  from  an  initial 
point ; proceeding  to  a certain  degree  of  development ; and  abat- 
ing and  disappearing.  In  the  first  stage  the  following  is  the  state. 
The  congestion  accumulated  to  one  point  is  thence  extended  to  the 
circumference.  Thither  the  blood  flows  ; its  motion  is  quickened ; 
the  walls  of  the  vessels  are  tense ; the  globules  of  arterial  blood 
are  no  longer  changed  into  venous  ; they  are  altered  ; the  paren- 
chyma is  swelled. 

This  state  of  the  vessels  takes  place  at  the  same  time  in  all  points 
of  the  organ  which  is  the  seat  of  congestion.  Not  only  is  the  cir- 
culation of  the  blood  altered.  The  blood  itself,  the  parenchyma, 
and  the  arterial  walls  partake  in  the  common  afiection.  The  nor- 
mal functions  of  the  organ  are  impeded ; the  formation  and  absorp- 
tion of  lymph  are  in  general  interrupted. 

The  affection  advances  to  different  degrees  of  intensity  accord- 
ing to  the  nature  and  severity  of  the  lesion  by  which  it  is  produced. 
The  afflux  of  blood  is  more  or  less  abundant ; its  motion  more  or 


140 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


less  accelerated ; the  vascular  walls,  especially  the  arterial,  are  more 
or  less  tense  ; the  blood  is  variously  altered  ; the^extent  of  the  pro- 
cess varies ; in  certain  cases  it  is  directly  proportional  to  its  inten- 
sity, and  in  others  it  is  not. 

The  extent  of  congestions  is  usually  limited  ; and  their  develop- 
ment is  completed  within  a short  time. 

When  congestion  has  attained  a certain  point,  it  remains  station- 
ary. It  then  attains  the  second  stage. 

This  is  not  distinguished  by  any  new  phenomenon.  The  pheno- 
mena of  congestion  are  already  established ; and  those  that  are 
essential  are,  afflux  of  blood  to  one  point;  acceleration  in  the  move- 
ment of  the  blood ; extension  of  the  process  little  beyond  its  initial 
point ; tbe  functions  of  tbe  organ  embarrassed ; swelling  of  the 
■parenchyma  ; and  alteration  in  the  globules. 

This  condition  must  not  be  confounded  with  certain  derange- 
ments in  the  circulation  which  imitate  some  of  the  phenomena  of 
congestion.  These  derangements  are  irregular  and  proceed  from 
the  local  action  of  any  irritant,  the  effect  of  which  is  slight  and 
temporary.  Sometimes,  however,  these  derangements  are  follow- 
ed by  congestion  ; and  this  is  when  these  irritant  agents  act  more 
intensely  and  for  a longer  time. 

The  development  of  true  congestion  is  a successive  process,  and 
takes  place  only  when  the  immediate  action  of  the  irritant  cause 
has  ceased  to  act  on  the  organ. 

When  congestion  has  lasted  some  time  it  decreases  and  termi- 
nates in  the  following  manner. 

The  amount  of  blood  and  the  velocity  of  its  movement  begin  to 
diminisb  at  the  circumference  ; the  blood  seeming  to  flow  from  this 
region  towards  this  centre.  The  blood  during  the  course  furnishes 
an  exhalation  of  fluid,  which  takes  place  in  jets  through  the  capil- 
lary vessels,  and  in  general  at  the  surface  of  the  organ.  The  mo- 
ment of  the  exhalation  of  the  liquid  is  transitory ; but  it  is  often 
repeated  at  different  points  until  the  congestion  disappears.  It  is 
critical,  because  the  congestion  subsides  in  proportion  as  it  is  re- 
peated and  proceeds.  The  quality  of  the  secreted  matter  varies 
according  to  the  nature  of  the  affection.  It  is  often  bloody,  espe- 
cially in  the  lower  animals.  The  products  of  critical  exhalation 
may  always  be  easily  seen.  They  consist  of  small  red  patches  dis- 
persed through  the  parenchyma.  In  some  instances  serous  fluid  is 
discharged  through  the  blood-vessels ; and  in  this  case  the  liquid 
being  transparent  is  not  so  easily  observed. 


SYSTEM  OF  CAPILLARY  VESSELS,  &C. 


141 


It  is  evident,  that,  in  the  phenomena  now  ascribed  to  congestion, 
many  would  be  disposed  to  see  the  early  stage  of  inflammation. 
This,  howevei*,  Kaltenbrunner  distinguishes  as  a process  of  greater 
intensity,  with  more  varied  phenomena,  and  more  complex,  and  pre- 
senting greater  modifications.  The  difference,  nevertheless,  seems 
more  in  degree  and  stage  than  in  any  other  circumstance,  and  in  / 
the  effects  which  it  is  liable  to  produce  on  the  tissues  which  it  af- 
fects. 

Inflammation  like  congestion  has  a period  of  increase,  of  esta- 
blishment, and  one  of  decline,  often  with  destructive  effects. 

In  the  period  of  increase,  the  phenomena  agree  in  general  with 
those  of  congestion.  The  movement  of  the  blood  is  quickened ; the 
vessels  are  distended ; the  blood  is  altered.  After  this,  however, 
other  changes  are  observed.  The  blood  begins  to  move  less  quickly 
in  some  capillary  vessels,  and  at  length  stops  completely.  Thus 
are  formed  in  the  system  of  disease^  vessels  stases,  statical  or  stag-y^/^ 
nating  points,  which  increasing  occupy  a large  space  round  the 
paid  where  the  cause  of  inflammation  is  seated.  (An  eschar  pro- 
duced by  the  hot  iron.)  At  the  circumference  of  these  statical 
points  the  circulation  proceeds  rapidly.  Thus  inflammation  is  es- 
tablished. The  same  phenomena  appear  on  the  application  of 
muriate  of  soda,  alcohol,  sal-ammoniac,  or  corrosive  sublimate. 

The  stases  are  formed  in  the  following  manner.  At  the  com- 
mencement of  inflammation  the  blood  traverses  all  the  vessels  with 
great  velocity.  Soon,  however,  its  movement  becomes  slower  at 
first  in  certain  capillaries,  situate  on  the  central  point  of  inflamma- 
tory action.  Then  the  circulation  is  disturbed  ; its  motion  becomes 
unsteady ; the  blood  seems  to  oscillate  irregularly  in  the  canals ; 
lastly,  its  movement  is  entirely  stopped ; and  the  blood  stagnates  in 
different  points.  These  stagnating  points  progressively  increase, 
and  affect  even  the  smaller  veins ; but  they  rarely  take  place  in  the 
arteries. 

The  blood  never  stagnates  in  the  canals  so  as  to  fill  them  entirely. 

It  is  accumulated  in  certain  points  so  as  to  leave  void  part  of  the 
canals.  Those  in  which  the  blood  stagnates  are  relaxed. 

The  stagnating  points  are  so  much  more  diffused  and  dispersed, 
and  occupy  a space  more  extensive,  as  the  inflammation  is  more 
severe  and  has  been  of  longer  duration.  Their  presence  is  evinced 
by  the  redness  of  the  part  on  which  they  are  situate,  which  is  more 
intense  on  the  initial  point  than  on  the  circumference.  The  in- 


142 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


flammatory  I’edness  is  livid  when  the  inflammation  is  intense,  and 
the  statical  points  are  dispersed  and  diflFused. 

The  first  change  which  the  hlood  undergoes  in  an  inflamed 
part  is,  that  it  is  not  converted  into  venous  blood.  Next  to  this 
the  coagulability  is  increased,  so  that  the  globules  coalescing  form 
minute  clots.  Then  the  globules  forming  these  clots  are  decom- 
posed; for  they  are  surrounded  by  serous  liquid  which  exudes 
fi’om  them. 

The  colour  of  the  blood  is  in  like  manner  altered.  When  mu- 
riate of  soda  is  used,  it  gives  the  blood  a purple  tint ; the  use  of 
alcohol  imparts  a clear  colour ; that  of  corrosive  sublimate  a dull 
brown  colour. 

Kaltenbrunner  further  maintains,  that  often  in  the  course  of  the 
phenomena  of  inflammation  has  he  observed  the  formation  of  new 
vessels  or  canals  in  an  inflamed  organ.  The  globules  of  blood  are 
observed  to  spring  all  at  once  from  some  capillary  canal,  to  fall 
into  the  surrounding  parenchyma,  pave  a path  for  themselves,  and 
by  this  reach  another  canal.*  This  seems  to  confirm  the  idea  of 
Doellinger  and  Wedemeyer,  already  mentioned,  (p.  134.) 

These  form  the  principal  phenomena  of  inflammation  in  its  in- 
creasing and  to  its  established  periods.  After  that  the  phenomena 
observed  relate  to  an  advanced  stage,  which  has  been  usually  con- 
sidered as  that  of  effects.  To  these,  therefore,  I shall  revert  subse- 
quently. 

Upon  the  whole,  two  facts  may  be  considered  to  be  established 
regarding  the  state  of  the  capillary  vessels  of  an  inflamed  part. 
The  first  is,  that  these  vessels  are  unnaturally  and  unusually 
distended,  and  really  contain  more  blood  than  in  the  state  of 
health.  This  is  proved  not  only  by  incisions  into  inflamed  parts, 
but  by  dissections  of  every  part  and  organ  of  the  body.  The  se- 
cond is,  that  the  blood  moves  more  slowly  in  these  vessels  than  in 
the  healthy  state,  and  even  after  some  time  may  remain  entirely 
motionless.  This  is  also  established  by  observing  the  effects  of  in- 
flammation in  the  human  body,  but  especially  by  the  phenomena  of 
inflammation  excited  artificially  in  the  bodies  of  the  lower  animals. 

It  is  still  a point  to  he  ascertained,  whether  these  two  conditions 

* Experimenta  circa  statum  sanguinis  et  vasorum  in  Inflammatione.  Auctore  Doc- 
tore  Georgio  Kaltenbrunner  Monacliii,  1826. 

Recherches  Experimen tales  sur  I’lnflammation,  par  M.  G.  Kaltenbrunner,  Docteur 
en  Medecine.  Breschet  Repertoire  General  d’Anatomie,  et  de  Physiologie  Patholo- 
giques,  &c.  Tome  ivtrieme,  p.  201.  Paris,  1827. 


SYSTEM  OF  CAPILLARY  VESSELS,  &C. 


143 


constitute  what  may  be  termed  the  essence  of  inflammation  ; and 
it  is  still  undetermined  by  what  agency  these  states  are  induced  in 
the  capillary  system  of  any  tissue  or  organ.  On  this  head  it  may 
be  remarked,  that,  if  by  any  means  the  natural  velocity  with  which 
the  blood  moves  through  any  set  of  capillaries  be  diminished,  and 
continue  so,  the  quantity  of  blood  in  these  vessels  must  be  gradu- 
ally and  steadily  increased,  until  it  becomes  very  considerable. 
This  appears  to  be  one  cause  of  the  accumulation  of  blood  in  any 
part  which  is  in  the  state  of  inflammation. 

2.  Temporary  dilatation  of  the  capillaries  not  inflammatory. 
The  capillary  vessels  undergo  a temporary  dilatation  during  the 
progress  of  aneurism,  whether  allowed  to  go  on  naturally,  or  after 
the  application  of  the  ligature  to  the  arterial  trunk.  When  the 
collateral  circulation  has  been  fully  established  by  the  enlargement 
of  the  anastomosing  branches,  the  capillary  system  shrinks  to  its 
ordinary  size. 

3.  Extravasation.  When  the  capillary  vessels  of  any  part  have 
been  injured,  so  as  to  burst  or  give  way,  the  blood  which  they  con- 
tained is  eflFused  round  them,  and  into  the  cellular  or  other  structure 
of  the  part,  occasioning  sometimes  considerable  swelling,  and,  if 
near  the  surface,  a red,  blue,  or  yellowish  colour.  In  such  cir- 
cumstances the  blood  is  said  to  be  extravasated . and  the  change  of 
colour  is  termed  ecchymosis. 

4.  Mode  of  repair  ; union  hy  adhesion  and  granulation.  When 
they  are  divided  by  simple  incision,  they  pour  out  first  blood,  then 
serous  or  colourless  fluids,  lastly,  a semifluid,  which  undergoes  co- 
agulation, and  which  forms  the  uniting  medium  of  the  divided  sur- 
faces, {liquor  sanguinis,  or  blood-plasma.)  This  is  the  radical 
moisture  of  the  older  physiologists ; (Taliacotius,  Ambrose  Pare, 
Phioravant,  &c.);  the  balsam  of  Nature,  or  agglutinative  balsam 
of  Wiseman,*  the  gluten  of  Sauvages,  Gaubius,  and  Cullen,  the 

■*  “ But  in  regard  there  is  a certain  medium  which  answers  in  proportion  to  a glue, 
required  in  this  work,  Natirre  taketh  what  is  next  in  hand,  even  the  nouiishment  of 
the  part  which  is  hurt  to  make  it  of.  Uhi  morbus  ibi  remedium  is  here  as  an  oracle  ; 
where  the  disease  is,  there  is  the  remedy.  No  sooner  is  the  wound  made  but  the  bal- 
sam is  discovered.  Blood,  at  least  the  serous  part  of  it,  is  the  glue,  which  she  useth 
both  in  curing  by  the  first  and  second  intention.  The  first  being  performed  per  sym- 
physin,  i.  e.  a reunion  of  the  parts  without  any  medium,  by  which  word  I here  mean  any 
callus  or  flesh,  or  other  body  interposed  ; for  in  another  sense  the  balsam  of  Nature  is 
the  medium,  the  instrument  of  unity,  and  puts  the  parts  together  ; the  second  per  cys- 
sarcosin,  i.  e.  with  a medium  or  interposition  of  some  flesh  or  callous  substance,  that 


144 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


coagulating  or  organizahle  Igmph  of  Hunter,  and  the  glutinous  or 
albuminous  exudation  of  the  F rench  pathologists. 

According  to  the  observations  of  Hunter,  Baillie,  and  Home, 
this  lymph  is  afterwards  penetrated  with  minute  arteries  and  veins, 
or  acquires  a capillai'y  system  of  its  own ; and  in  this  state  it  is 
properly  organized  lymph.  This  process  of  formation  of  new  ca- 
pillaries occurs  in  every  situation  in  which  lymph  is  deposited  ; 

In  the  exudation  of  inflamed  serous  membranes,  which  afterwards 
forms  the  membrane  of  adhesions ; 2<^,  In  wounds  of  skin,  cellular 
membrane,  mucous  membrane,  muscle,  &c. ; 3tZ,  In  inflammation 
of  these  tissues,  whether  occurring  spontaneously,  in  consequence 
of  bruise  or  laceration,  or  the  introduction  of  foreign  bodies.  In 
each  of  these  cases,  though  suppuration  should  also  take  place, 
still  there  is  lymph  effused,  and  this  lymph  is  penetrated  by  newly 
formed  capillaries.  This  formation  of  new  capillaries  is  termed  by 
the  French  pathologists,  accidental  development  of  the  capillary  sys- 
tem. Is  it  lymph  of  a peculiar  kind  that  is  effused  from  the  ca- 
pillaries of  fractured  bones  in  the  first  stage  of  the  process  of  re- 
union ? The  substance  named  callus  is  not  cartilage,  as  was  an- 
ciently supposed,  and  possesses  qualities  not  unlike  those  of  the 
•lymph  of  soft  tissues.  Is  lymph  effused  from  the  fragments  of  a 
broken  cartilage,  or  a ruptured  tendon  ? In  each  of  these  cases 
of  injury,  a soft  homogeneous  fluid,  pale  red  or  bluish,  is  effused 
immediately  or  soon  after  the  injury  ; and  in  each  it  seems  to  pos- 
sess the  same  qualities,  and  only  in  the  course  of  the  process  of  re- 
union to  be  afterwards  penetrated  by  the  peculiar  matter  of  the 
tissue  injured.  A preliminary  step  to  this  penetration  of  proper 
substance  is  uniformly  the  formation  of  new  capillary  arteries  and 
veins. 

In  those  examples  of  spontaneous  disease  or  injury  in  which  sup- 
jH  puration  takes  place,  the  capillaries  in  depositing  lymph  are  con- 
cerned in  another  process,  the  formation  of  red  eminences,  hemi- 
spherical or  hemispheroidal,  of  various  size,  and  varying  in  firm- 
ness or  consistence.  This  process  has  been  termed  granulation.^  a 
name  which  has  been  also  improperly  given  the  individual  bodies. 
The  simplest,  and  perhaps  the  most  correct  view  of  this  process, 
shows  that  it  consists  of  three  distinct  stages,  which  it  is  important 
for  the  pathologist  to  know. 

fills  up  the  space  between  the  lips  of  the  wound.” — Chirurgical  Treatises  by  Richard 
Wiseman,  Sergeant-Surgeon,  Book  v.  Chap.  1.  Of  Wounds. 


SYSTEM  OF  CAPILLARY  VESSELS,  &C. 


145 


a.  The  first  of  these  consists  in  eflTusion  of  lymph,  or  rather  sero- 
albuminous  fluid  or  liquor  sanguinis,  from  capillary  arteries  in  the  li- 
quid form,  and  which  speedily  undergoing  coagulation  as  it  exudes, 
is  converted  into  irregular  globules  or  masses.  The  extent  to  which 
this  exudation  takes  place  will  depend  on  the  extent  of  the  surface 
and  the  degree  of  inflammation  ; and  the  same  principles  will  regu- 
late the  appearance  of  the  globules  or  masses  of  lymph  in  the  diflre- 
rent  points  of  the  granulating  surface. 

b.  After  these  globules  have  been  effused  and  coagulated,  they 
are  soon  penetrated  with  vessels  which,  according  to  Hunter,  may 
be  justly  esteemed  mere  prolongations  of  the  capillaries  which  ori- 
ginally secreted  the  lymph.  This  penetration  of  vessels  constitutes 
what  may  be  considered  the  second  stage  of  granulation.  This 
process,  which  must  have  been  observed  by  many  practical  sur- 
geons, has  been  clearly  and  correctly  described  by  Hunter.  ‘‘  I 
have  often,”  says  he,  ‘‘  been  able  to  trace  tbe  growth  and  vascula- 
rity of  this  new  substance.  I have  seen  on  a sore  a white  substance 
exactly  similar  to  coagulating  lymph.  I have  not  attempted  to 
wipe  it  off,  and  the  next  day  of  dressing  I have  found  this  very 
substance  vascular  ; for  by  wiping  or  touching  it  with  a probe  it 
has  bled  freely.”  And,  again,  “ The  vessels  of  granulations  pass 
from  the  original  parts,  whatever  these  are,  to  the  basis  of  the  gra- 
nulations, from  thence  toward  their  external  surface,  in  pretty  re- 
gular parallel  lines,  and  would  almost  appear  to  terminate  there.”* 
At  the  same  time  the  formation  or  secretion  of  purulent  fluid  goes 
on ; and  the  surfaces  of  these  bodies  themselves  acquire  the  same 
power  of  preparing  this  fluid  which  the  surface  fi-om  which  the  gra- 
nulations were  produced,  possessed.  In  this  instance  we  have  an 
example  of  capillary  vessels  performing  at  the  same  time  the  effu- 
sion of  lymph  and  the  secretion  of  purulent  fluid. 

In  this  stage  of  the  process  of  granulation,  Mr  Hunter  has 
remarked  the  disposition  to  union,  ohesion,  or  adhesion,  which 
granulating  eminences  possess,  and  described  the  mechanism  by 
which  this  is  accomplished.  By  many  it  might  be  deemed  a 
distinct  process.  But  in  so  far  as  the  capillaries  are  concerned,  the 
chief  object  of  consideration  at  present,  it  is  to  be  viewed  as  a part 
of  the  second  stage.  The  vessels  of  the  granulating  eminences 
continue  to  secrete  lymph,  which  unites  the  corresponding  surfaces 
of  their  new  bodies  till  their  capillaries  pass  into  each  other,  so  as 
to  inosculate,  and  the  union  is  completed. 

* II.  p.  477. 

K 


146 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


c.  The  third  stage  in  the  process  of  granulation  consists  in  what 
he  has  termed  contraction.  In  describing  this  important  part,  I fear 
he  has  committed  two  errors — one  in  looking  at  the  whole  granu- 
lating surface  and  contiguous  parts,  rather  than  at  the  individual 
bodies ; the  other  in  ascribing  contraction  to  the  elasticity  and  mus- 
cular action  of  the  contiguous  parts  rather  than  to  a change  in  the 
state  of  the  granulations.  These  circumstances  are  certainly  use- 
ful accessory  means  ; but  they  must  not  be  regarded  as  the  primary 
and  essential  cause.  Perhaps  also  some  slight  differences  take 
place  in  the  time  in  which  contraction  occurs,  and  the  extent  to 
which  it  proceeds,  according  to  the  nature  of  the  granulating  sur- 
face, and  the  relation  which  the  production  of  the  granulating  emi- 
nences bears  to  the  part  to  be  restored.  The  general  phenomena 
of  the  process  appear  to  be  the  following. 

After  the  granulating  eminence  or  eminences  have  been  form- 
ed, and  have  united  with  the  contiguous  ones,  the  uninterrupted 
action  of  their  new  capillaries  continues  to  effuse  lympli  as  a basis 
for  fresh  granulations,  and  to  give  out  vascular  or  capillary  pro- 
longations, in  order  to  organize  them.  Meanwhile  the  vessels  of 
the  granulating  eminences  near  the  edges  of  the  surface  begin  to 
diminish  in  size ; and  as  they  diminish  the  eminences  themselves 
become  less  red  and  smaller,  but  more  firm.  At  length,  as  the 
eminences  become  covered  with  the  membrane  of  cicatrization,  they 
appear  to  have  diminished  so  much,  that  little  inequality  can  be  re- 
cognised, the  redness  is  sensibly  diminished,  and  the  whole  appears 
as  if  it  were  becoming  quite  as  solid  or  firm  as  the  contiguous 
parts.  If  in  this  part  of  the  process  a granulating  surface  be  inject- 
ed, the  vessels  which  go  to  the  outer  granulating  eminences  will  be 
found  to  be,  Is^,  much  less  numerous ; and,  2J,  to  be  mucb  dimi- 
nished in  size ; and  this  change  will  be  observed  to  be  most  re- 
markable at  the  edge,  and  less  at  the  centre  of  the  sore.  It  is  this 
diminution  in  the  number  and  size  of  the  granulating  capillaries 
which  is  the  main  agent  of  the  process  of  contraction.  As  these 
vessels  become  less  numerous  and  smaller,  the  bodies  to  which  they 
are  distributed  diminish  and  become  firmer ; and  if  a wound  or 
part  wbich  has  been  healed  by  granulation  be  injected  some  weeks 
or  months  after  being  healed,  the  vessels  will  be  actually  found 
less  numerous  and  smaller  than  in  the  contiguous  parts  of  the  same 
tissue. 

When  union  by  granulation  is  accompanied  with  the  formation 


SYSTEM  OF  CAPILLARY  VESSELS,  &C. 


147 


of  a thin  membrane,  which  afterwards  assumes  the  appearance  and 
properties  of  skin,  the  last  part  of  the  process  is  called  shinning  or 
cicatrization^ — the  formation  of  a scar.  The  nature  and  mechanism 
of  this  process  will  be  considered  in  its  proper  place. 

Granulation  may  be  viewed  as  the  means  which  the  several  tis- 
sues of  the  human  body  possess  of  reproducing  themselves,  or  re- 
pairing those  losses  of  substance  which  result  from  direct  injury,  or 
take  place  in  consequence  of  disease.  Of  this  process  the  capilla- 
ries of  the  texture  are  the  agents.  But  it  is  uncertain  to  what  ex- 
tent they  possess  the  power  of  reproducing  the  same  sort  of  sub- 
stance as  that  of  the  texture  destroyed.  The  kind  of  matter  v/hich 
is  most  generally  reproduced  is  filamentous  or  cellular  tissue.  It 
is  certain  also  that  bone  is  reproduced.  But  it  is  uncertain  whe- 
ther skin,  that  is  true  skin,  muscle,  teudon,  or  ligament,  is  repro- 
duced, and  almost  certain  that  cartilage  is  not. 

5.  Different  effects  of  inflammation.  I have  said  that  granula- 
tion is  in  general  accompanied  with  the  formation  of  more  or  less 
purulent  matter.  This  process,  which  is  termed  suppuration,  ge- 
nerally precedes  that  of  granulation.  It  has  been  viewed  at  one 
time  as  a consequence  or  effect  of  inflammation,  at  another  as  a 
character  of  it,  and  at  a third  as  a cause.  The  circumstances 
which  justify  these  distinctions  should  be  understood. 

Inflammation  is  a progressive  process,  which  tends  through  cer- 
tain stages  to  a certain  termination.  Of  the  intermediate  steps  not 
much  is  known  with  certainty  ; and  pathological  writers  have  dis- 
tinguished chiefly  the  different  modes  in  which  it  may  terminate. 
These  are  resolution,  effusion,  adhesion,  suppuration,  granulation, 
ulceration,  cicatrization,  induration,  and  gangrene.  This  division 
is  more  scholastic  than  natural.  The  first  only  can  be  justly  de- 
nominated a termination.  All  the  others  are  to  be  regarded  as 
effects  either  immediate  or  remote  of  the  process. 

a..  Resolution  is  that  action  in  which  the  redness,  pain,  heat,  and 
swelling  of  an  inflamed  part  gradually  disappear,  either  spontane- 
ously or  under  the  use  of  means,  with  or  without  sensible  evacua- 
tion, and  in  which  the  part,  which  had  been  inflamed,  resumes  by 
degrees  its  natural  state,  without  suffering  derangement  of  structure 
or  properties.  This  is  exceedingly  rare.  The  minute  veins  are 
doubtless  the  great  agents  of  cure  in  such  circumstances. 

(3.  In  most  cases  of  inflammation  more  or  less  fluid  is  early  effus- 
ed or  extravasated  from  the  capillaries  or  the  exhalants  of  the  part. 


148 


GENERAL' AND  PATHOLOGICAL  ANATOMY. 


No  sooner  do  the  vessels  become  overloaded  with  blood  than  part 
of  it  either  entire,  or  in  the  form  of  serous  fluid,  is  separated  from 
the  vessels.  Thus  in  inflammation  of  filamentous  tissue  blood  or 
serum  may  be  poured  into  its  interstitial  spaces ; and  the  effusion 
of  the  latter  is  one  cause  of  oedematous  and  anasarcous  infiltration. 
In  inflammation  of  the  serous  membranes  also  we  shall  find  that 
effusion  of  serous  fluid  is  an  eaidy  and  frequent  result. 

When  this  effusion  is  moderate  it  may  be  removed  under  suit- 
able management  by  the  action  of  the  veins  and  lymphatics ; and 
in  siich  circumstances  this  termination  would  still  come  under  the 
head  of  resolution. 

7.  In  general,  however,  the  fluid  effused  is  of  a more  compli- 
cated nature.  The  natural  tendency  of  the  process  of  inflamma- 
tion is  to  cause  the  vessels  to  secrete  or  exhale,  or  effuse  a fluid 
which  at  once  contains  coagulable  lymph  and  a thinner  serum, 
which,  at  a later  period,  at  least  in  the  filamentous  tissue,  corre- 
sponds to  sero-purulent  or  purulent  fluid.  The  serum  is  not  con- 
verted, as  Cullen  imagined,  into  purulent  matter.  But  the  same 
vessels  which,  at  an  early  stage  of  the  process,  secrete  serous  fluid 
containing  lymph,  at  a more  advanced  period  secrete  purulent  mat- 
ter. This  is  easily  proved  by  tracing  the  progressive  changes  in  a 
large  wound  ; for  instance  an  amputated  stump,  an  incision  made 
into  an  inflamed  swelling,  or  an  Incision  made  on  purpose  into  the 
soft  parts  of  an  animal.  The  same  general  conclusion  results  also 
from  observing  the  progressive  steps  in  the  human  body  after  a 
seton  has  been  inserted,  or  an  issue  established.  In  the  case  of  part 
of  the  surface  being  destroyed  by  caustic,  actual  or  potential,  the 
process  may  be  less  distinctly  observed ; but  it  is  still  nearly  the 
same. 

Upon  the  whole,  the  natural  course  of  phenomena  in  inflamma- 
tion may  be  stated  in  the  following  order.  First,  vessels  dilated 
and  distended  with  blood,  which  moves  more  slowly  than  natural. 
Secondly,  the  secretion  or  effusion  from  these  vessels,  or  their  ex- 
halant  terminations,  of  a fluid  consisting  of  serum  and  coagulable 
matter,  sometimes  with  extravasation  of  blood.  Thirdly,  the  se- 
cretion of  purulent  fluid  from  the  same  vessels. 

The  intimate  nature  of  the  process  by  which  purulent  matter  is 
formed  is  by  no  means  well  known.  The  notion  of  Grashuys,  * 
that  it  arose  from  a liquefaction  or  melting  of  the  adipose  tissue, 

* De  Suppuratione. 


149 


SYSTEM  OF  C-VPILLARY  VESSELS, '^C. 

though  adopted  by  Haller,*  is  too  ridiculous  to  merit  the  slightest 
attention.  It  is  sufBcient  to  remark,  that  purulent  matter  is  pre- 
pared by  many  other  tissues  which  contain  no  adipose  matter ; for 
instance  the  mucous  and  serous  membranes,  and  several  of  the 
glandular  organs,  internal  and  external.  The  fallacy  of  the  opi- 
nion of  Cullen,  which  was  derived  from  the  experiments  of  Pringle 
and  of  Gaber,  has  been  already  noticed. 

The  view  of  Hunter  is,  on  the  whole,  more  correct.  In  inflam- 
mation of  the  filamentous  tissue,  where  the  parts,  or  more  accu- 
rately, the  vessels  lose  the  power  of  resolution,  they  begin  to  “ alter 
their  mode  of  action,  and  continue  changing  till  they  gradually 
form  themselves  to  that  state  which  fits  them”  to  prepare  purulent 
matter.  This  applies,  however,  only  to  the  case  in  which  lymph  is 
exuded  and  purulent  matter  is  secreted,  simultaneously  or  succes- 
sively, or,  in  other  words,  to  the  transition  from  the  adhesive  to  the 
suppurative  stage.  In  certain  circumstances  this  transition  does 
not  take  place,  and  purulent  fluid  may  be  secreted  without  the  pre- 
vious effusion  of  coagulable  lymph.  The  first  action  of  the  vessels 
is  then  to  pour  forth  serous  fluid,  and  the  next  is  the  secretion  of 
purulent  matter  in  a more  or  less  perfect  form.  This  is  well  ex- 
emplified in  diffuse  inflammation  of  the  filamentous  tissue. 

No  doubt  can  be  entertained,  from  the  experiments  of  Brug- 
mann,  f Hunter,  | and  Home,  § and  from  the  daily  phenomena  of 
purulent  collections,  that  suppuration  is  a process  analogous  to,  if 
not  the  same  as  secretion.  || 

This  is  demonstrated  in  the  case  of  mucous  and  serous  mem- 
branes, in  which  purulent  matter  is  formed  without  breach  of  sur- 
face, and  in  which,  therefore,  its  formation  must  be  ascribed  to  a 
new  action  of  the  vessels.  It  does  not,  however,  follow  from  this 
that  these  vessels  perform,  as  Hunter  imagined,  the  office  of  a gland. 
This  notion  appears  to  be  adopted  merely  to  render  the  conception 
of  suppuration  more  distinct  than  it  would  be  if  simply  ascribed  to 
the  action  of  vessels. 

Suppuration  is  the  direct  and  exclusive,  or  the  concurrent  effect 
of  inflammation.  It  is  generally  the  direct  eflfect  in  inflammation 
of  the  mucous  membranes,  often  in  that  of  the  serous  membranes, 

* Elementa,  Lib.  i.  sect.  4.  f De  Puogenia.  8vo.  Groningte,  1781. 

J Treatise  on  the  Blood,  Inflammation,  &c.  Chap.  v. 

§ On  the  Properties  of  Pus.  4to.  London,  1788. 

II  “ This  new  structure  or  disposition  of  vessels  I shall  call  glandular,  and  the  effect 
or  pus  a secretion.”  Chap.  v. 


150 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


and  it  is  so  in  diffuse  inflammation  of  the  filamentous  tissue.  In 
circumscribed  inflammation  in  the  filamentous  tissue,  in  inflamma- 
tion of  the  skin,  and  occasionally  in  inflammation  of  the  serous  mem- 
branes, it  is  preceded  by  exudation  of  coagulable  lympb,  and  is 
either  concurrent  or  successive  to  it. 

Suppuration  is  represented  by  Hunter  as  always  preparatory  to 
granulation.  This,  however,  must  be  understood  to  apply  to  sup- 
puration of  cellular  tissue,  and  those  textures  of  which  it  makes 
part.  In  mucous  and  serous  membranes  suppuration  may,  and  al- 
most invariably  does,  take  place  without  granulation.  I shall  af- 
terwards have  occasion  to  mention  another  sort  of  purulent  collec- 
tions, in  which  granulation  never  occurs. 

Suppuration  varies  according  to  the  nature  of  the  inflammatory 
process  which  it  succeeds,  and  according  to  the  texture  in  which  it 
takes  place. 

As  inflammation  varies  according  to  the  nature  of  the  texture  in 
which  it  takes  place,  so  its  effects  are  different  in  the  different  or- 
ganic textures.  The  purulent  matter  formed  on  the  skin  differs 
from  that  which  flows  from  an  abscess  of  the  cellular  tissue.  That 
secreted  by  mucous  membranes  is  different  from  either ; and  even 
the  purulent  fluid  of  serous  membranes  possesses  certain  charac- 
ters by  which  a careful  observer  may  distinguish  it  from  the  same 
fluid  in  other  situations. 

The  suppurating  process  may  be  varied  according  to  the  nature 
of  the  inflammation  by  which  it  is  preceded.  A sound  principle 
laid  down  by  John  Hunter  was  to  regard  every  form  of  suppura- 
tion as  the  result  of  inflammation.  From  this,  however,  he  depart- 
ed in  his  views  of  the  nature  of  suppurations  of  lymphatic  glands, 
of  diseased  joints,  of  lumbar  abscesses,  and  of  the  cold  or  chronic 
abscess  in  general.  * It  is  easy  to  show,  that,  with  the  single  ex- 

• Many  indolent  tumours,  slow  swellings  in  the  joints,  swellings  of  the  lymphatic 
glands,  tubercles  in  the  lungs,  and  swellings  in  many  parts  of  the  body,  are  diseased 
thichenings,  wthout  visible  inflammation.  And  the  contents  of  some  kinds  of  encyst- 
ed tumour  ; the  matter  of  many  scrofulous  suppurations,  as  in  lymphatic  glands  ; the 
suppuration  of  many  joints,  viz.  those  scrofulous  suppurations  in  the  joints  of  the  foot 
and  hand,  in  the  knee,  called  white  swellings  ; in  the  joint  of  the  thigh,  commonly 
called  hip-cases  ; in  the  loins,  called  lumbar  abscesses  ; the  discharge  of  the  above- 
mentioned  tubercles  in  the  lungs,  as  well  as  in  many  other  parts  of  the  body,  are  all 
matter  formed  without  any  previous  visible  inflammation,  and  are  therefore  in  this 
one  respect  all  very  similar  to  one  another.  They  come  on  insensibly,  the  first  symp- 
tom being  commonly  the  swellings,  in  consequence  of  the  thickening,  which  is  not  the 
case  with  inflammation  ; for  there  the  sensation  is  the  first  symptom,” — Treatise,  Chap, 
iv.  IV.  p.  391. 


151 


SYSTEM  OF  CAPILLAEY  VESSELS,  &G. 

ception  of  pulmonary  tubercles,  in  every  one  of  the  instances  which 
he  has  adduced  the  formation  of  fluid  matter,  is  invariably  preceded 
by  inflammation,  that  is,  by  morbid  enlargement  of  the  capillaries  / 
of  the  aflPected  texture. 

In  the  case  of  lymphatic  glands  suppurating,  these  bodies  inva- 
riably enlarge  previously,  and  are  always  the  seat  of  dull  heavy 
pain.  This  enlargement  depends  either  on  the  vessels  undergoing 
a slow  process  of  dilatation  and  distension,  or  on  the  formation  of 
tubercles  in  the  substance  of  the  gland. 

The  affections  of  the  knee-joint,  hip-joint,  and  other  articulations, 
have  been  satisfactorily  traced  to  inflammation  either  of  the  synovial 
apparatus,  or  of  the  cartilages,  or  of  both,  passing  on  the  one  hand 
to  the  capsule,  and  on  the  other  to^the  bones.  During  life  they 
are  painful,  generally  swelled  or  enlarged,  and  invai’iably  hotter 
than  natru’al.  Dissection  shows  these  parts  to  be  more  or  less, 
sometimes  highly,  vascular. 

The  collections  denominated  lumbar  abscess  depend  either  on 
disease  of  the  vertebrm,  generally  of  an  inflammatory  nature,  or 
on  slow  inflammation  of  the  lumbar  cellular  tissue  and  lymphatic 
glands. 

The  circumstance  in  which  Mr  Hunter  trusted,  in  considering  these 
collections  to  be  independent  of  inflammation,  was  the  absence  of 
pain  as  the  first  symptom.  In  this,  however,  I believe  that  accu- 
rate observer  was  mistaken.  In  every  one  of  the  cases  of  disease 
to  which  he  refers  as  examples,  more  or  less  pain  is  invariably  felt 
in  the  course,  if  not  from  the  first  date  of  the  complaints.  Two 
circumstances,  indeed,  distinguish  this  sort  of  pain.  It  is  neither 
severe  nor  uninterrupted,  and  may  be  so  moderate  as  not  to  attract 
the  attention  of  the  patient,  or  form  a serious  subject  of  complaint. 
But  even  admitting  the  statement  of  Mr  Huntei’,  that  the  sensation 
of  pain  is  not  the  first,  it  is  doubtless  too  limited  a view  of  the  in- 
flammatory process  to  imagine,  that  this  can  never  exist  unless 
when  the  sensation  of  pain  is  the  first  symptom.  In  some  of  the 
textures,  especially  mucous  membrane,  we  know  that  inflammation 
may  be  established  for  some  time  without  much  attendant  pain. 

In  others,  especially  the  serous  membranes,  inflammation  approaches 
so  slowly  and  imperceptibly,  that  both  lymph  and  purulent  matter 
may  be  effused  before  the  existence  of  the  disease  is  suspected. 

For  these  and  similar  reasons  it  has  become  requisite  to  admit 
the  existence  of  a slow  insidious  form  of  inflammation  termed  chronic. 


152 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


corresponding  to  the  inflammation  hy  congestion  of  Pare,  Hildanus, 
Wiseman,  and  the  older  surgeons,  and  causing  the  cold  abscess  to 
whieh  I had  occasion  formerly  to  allude.  But,  with  the  exception 
of  its  being  attended  with  little  or  no  pain,  and  proceeding  much 
more  slowly  than  acute  inflammation,  little  is  known  regarding  the 
anatomical  and  pathological  characters  of  this  form  of  the  process. 
From  several  circumstances  it  might  be  inferred  that  the  capillaries 
begin  to  assume  the  suppurative  action,  at  least  in  fllamentous  tis- 
sue, more  readily  than  in  the  case  of  acute  inflammation.  In  other 
parts  chronic  inflammation  may  exist  without  terminating  in  the 
suppurative  process. 

In  cases  in  which  the  acute  seems  to  be  combined  with  the  chronic, 
so  as  to  form  an  intermediate  or  mixed  variety  of  disease,  it  has 
been  distinguished  by  the  name  of  subacute  inflammation. 

Under  certain  circumstanees  chronic  inflammation  may  terminate 
in  the  acute.  Thus  an  abscess  in  the  cavity  of  a joint,  either  by 
distension  or  by  propagation  of  action,  may  induce  inflammation  in 
the  subcutaneous  cellular  tissue  and  in  the  skin.  When  a chronic 
abscess  is  opened,  its  whole  interior  surface  is  attacked  with  acute 
inflammation ; and  when  a lumbar  abscess  is  opened,  or  is  allowed 
to  burst,  the  same  effect  results.  By  carefully  excluding  the  air, 
indeed,  and  healing  up  the  wound  according  to  the  manner  of  Mr 
Abernethy,  the  severity  of  this  inflammation  may  be  much  mitigat- 
ed ; but  it  always  takes  place,  and  sooner  or  later  becomes  gene- 
ral and  severe.  In  this  sense  only  can  suppuration  be  said  to  cause 
inflammation.  But  the  proper  view  of  the  relation  of  these  two 
processes  is,  that  chronic  inflammation  may  cause  the  acute  form 
by  the  capillaries  assuming  a new  mode  of  action,  or  by  propagat- 
ing the  irritation  to  those  of  a new  texture.  In  circumstances  of 
this  description,  suppuration  is  in  general  without  granulation  or 
attempt  at  repair. 

h.  Suppuration  may  be  either  without  attempt  at  repair,  or  with 
absolute  destruction  of  texture ; and  it  is  then  distinguished  as  ul- 
ceration, or  the  formation  of  an  ulcer.  Since  the  time  of  Hunter, 
who  gave  the  first  clear  idea  of  this  process,  ulceration  has  been 
generally  understood  to  consist  in  absorption  with  suppuration. 
This  notion  is  perhaps  more  hypothetical  than  the  old  one  of  breach 
of  surface  or  loss  of  substance,  which  simply  expressed  the  fact 
without  reference  to  its  supposed  cause.  But  as  loss  of  substance 
implies  the  absorption  or  resumption  of  part  of  the  animal  texture. 


SYSTEM  OF  CAPILLAEY  VESSELS,  &C. 


153 


and  as  this  must  be  understood  to  be  effected  by  the  vessels  of  the 
part,  the  chief  objection  with  which  this  opinion  can  be  charged,  is, 
that  not  only  the  lymphatics,  but  the  minute  veins  must  be  con- 
cerned in  the  process  of  resumption. 

I do  not  propose  here  to  consider  all  the  various  forms  of  ulce- 
ration, or  the  circumstances  under  which  it  may  take  place.  But 
I shall  mention  a few  by  way  of  example. 

Ulceration  occurs  in  the  skin  in  consequence  of  inflammation 
from  injury,  as  wound,  tear,  burn,  &c.,  death  of  a part  occasioned 
either  by  mortification,  or  by  the  cautery,  actual  or  potential,  or  the 
application  of  a morbid  poison. 

Ulceration  occurs  in  the  mucous  membranes  under  the  same 
circumstances  as  in  the  skin,  and  also  after  spontaneous  inflamma- 
tion, that  is,  inflammation  coming  on  without  manifest  cause. 

Ulceration  occurs  in  the  cellular  tissue  in  consequence  of  the 
pressure  and  progressive  advancement  of  a large  abscess,  in  conse- 
quence of  the  presence  of  foreign  bodies,  as  bullets,  sword-points, 
pins,  &c. ; or  the  sharp  end  of  a bone. 

Ulceration  is  not  common  in  serous  membranes.  In  these,  how- 
ever, it  takes  place  in  consequence  of  the  continued  pressure  of 
large  collections  of  matter.  This  is  seen  in  empyema  and  collec- 
tions of  purulent  matter  in  the  peritonaeum. 

Ulceration  occurs  in  bone  either  spontaneously,  or  in  conse- 
quence of  the  death  of  part  of  it.  The  former  is  seen  in  caries, 
the  latter  in  necrosis  and  exfoliation. 

Ulceration  occurs  in  cartilage  in  consequence  of  inflammation. 
This  is  seen  in  diseases  of  the  knee-joint  and  hip-joint. 

In  all  cases  of  ulceration,  the  capillaries  of  the  parts  are  larger 
and  more  numerous  than  natural,  and  certainly  contain  more  blood 
than  in  the  state  of  health.  This  is  seen  very  well  in  the  case  of 
ulcers  of  the  cornea,  which  are  invariably  surrounded  by  an  annu- 
lar net-work  of  small  vessels,  which  in  the  sound  state  of  that  tex- 
ture are  invisible.  In  the  skin  it  is  very  well  established  by  inci- 
sions made  in  the  treatment  of  boil  and  carbuncle.  In  both  cases, 
if  the  incision  be  carried  through  either  tumour,  much  more  blood 
is  discharged  from  the  point  where  ulceration  is  established  than  at 
any  other  part.  The  same  fact  is  demonstrated  by  the  appearance 
of  ulcerated  patches  of  the  intestinal  mucous  membrane. 

In  the  process  of  ulceration  it  is  generally  possible  to  trace  a 
final  intention  or  definite  purpose,  after  the  accomplishment  of 


154 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


which  it  ceases  spontaneously.  It  takes  place  under  circumstances 
in  which  it  is  requisite  to  remove  some  part  of  a texture  which  is 
either  unsound,  or  has  become  foreign  to  the  system,  as  in  the  case 
of  dead  bones,  mortified  sloughs,  or  to  procure  an  outlet  for  some 
morbid  fluid,  as  is  seen  in  deep  purulent  collections,  or  to  expel  a 
foreign  body  from  a situation  in  which  its  presence  is  injurious. 
Hence  it  has  been  justly  remarked  by  Hunter,  that  every  process 
of  ulceration  is  preceded  by  adhesive  inflammation  at  one  or  more 
points,  sometimes  round  the  whole  line  along  which  the  ulcerating 
process  takes  place.  The  object  of  this  is  to  prevent  hemorrhage 
by  the  closure  of  vessels,  and  to  prevent  the  diffusion  of  purulent 
fluid  in  situations  where  its  presence  would  be  injurious.  In  se- 
veral situations,  however,  it  fails  to  accomplish  this  purpose. 

When  the  ulcerative  process  has  effected  the  object  for  which  it 
was  commenced,  a new  mode  of  action  takes  place.  The  vessels 
begin  to  deposit  lymph  in  rounded  masses,  which  become  vascular, 
and  all  the  phenomena  of  granulation  succeed.  In  such  circum- 
stances, are  we  to  suppose  that  the  absorbing  process  has  given  way 
to  that  of  deposition, — the  action  of  veins  and  lymphatics  to  that 
of  minute  arteries  ? 

In  certain  situations,  this  process  of  deposition  may  be  observed 
going  on  in  one  part  of  a sore,  while  that  of  removal,  destruction, 
or  absorption  is  proceeding  in  another.  Thus  in  an  eschar  occa- 
sioned by  a burn,  or  by  cautery,  actual  or  potential,  while  the  pro- 
cess of  ulceration  is  detaching  the  margin  of  the  slough,  a crop  of 
granulations  may  be  observed  rising  with  equal  rapidity  and  stea- 
diness, and  pushing  off,  as  it  were,  the  dead  substance.  The  phe- 
nomena of  these  and  similar  processes  present  objections  to  the 
theory  of  Hunter. 

E.  Softening  (^Malacismus  ; JEnallaxis  ; Sphacelismus  ;)  or  pre- 
ternatural diminution  of  consistence,  is  an  effect  of  inflammation, 
which  in  different  tissues  is  liable  to  ensue.  The  tissues  in  which 
it  is  most  frequent  are  the  brain,  spinal  chord  or  nerves,  the  lungs, 
the  uterus,  and  the  bones.  It  consists  in  the  more  or  less  com- 
plete separation  of  the  component  atoms  of  these  tissues,  whether 
fibrous,  globular,  or  amorphous,  by  the  destruction  or  dissolution 
of  their  filamentous  tissue,  and  occasionally,  if  not  constantly,  with 
the  substitution  of  serous,  sero-albuminous,  sero-sanguine,  or  sero- 
purulent  fluid.  The  characteristic  organization  of  the  tissue  is,  in- 
deed, more  or  less  completely  destroyed.  Its  elasticity  and  te- 


SYSTEM  OF  CAPILLAEY  'VTISSELS,  &C. 


155 


nacity  are  destroyed;  and  it  is  rendered  lacerable.  In  certain 
tissues,  especially  that  of  the  lungs,  and  perhaps  that  of  the  hrain 
occasionally,  softening  is  analogous  to  mortification  of  other  tissues. 
In  the  hrain,  however,  it  is  most  usually  analogous  to  suppuration. 

One  variety  of  softening  is  often  observed  in  parts  or  new  struc- 
tures, originally  hard,  and  consists  not  so  much  in  the  process  now 
mentioned,  as  in  the  slow  solution  or  liquefaction  of  the  tissue  or 
substance,  partly  by  disruption  of  its  particles,  partly  by  death  of 
their  individual  atoms,  with  the  admixture  of  blood,  serous  or  sero- 
purulent  fluid.  This  softening,  which  takes  place  in  encysted  tu- 
mours, tyromatous  or  scirrhous  tubercles,  and  in  most  of  the  ad- 
ventitious tissues,  is  a spurious  variety  of  suppuration. 

Induration  (iS'cZero?72a,  Verb  art  ung),  or  preternatural  firm- 
ness, is  a usual  concomitant  and  effect  of  the  process  of  inflamma- 
tion, The  process  rarely,  indeed,  exists  for  a few  hours  or  days 
in  any  tissue  without  rendering  it  considerably  harder  and  more 
resisting  than  natural.  In  the  external  parts  of  the  body  this  is 
seen  in  inflammation  of  the  skin  and  filamentous  tissue,  in  which 
the  inflamed  parts  are  much  harder  and  firmer  than  natural ; and 
every  inflammation  of  the  filamentous  tissue  is  accompanied  with 
hardness  more  or  less  extensive.  This  hai’dness,  which  is  also  ac- 
companied with  swelling  and  enlargement,  depends  partly  on  the 
excessive  distension  of  vessels  by  blood,  and  partly  on  the  effusion 
of  sero-albuminous  fluid. 

The  latter  circumstance  explains  the  presence  of  induration  as 
a consequence  of  the  inflammatory  process.  The  sero-albuminous 
fluid,  though  first,  when  eflPused,  liquid,  and  homogeneous,  is 
speedily  separated  by  virtue  of  its  property  of  spontaneous  coagu- 
lation into  two  parts, — the  serous,  liquid,  or  non-coagulable, 
and  the  albuminous,  consistent,  or  coagulable.  The  former  is  the 
cause  of  the  oedematous  swelling  already  mentioned  as  often  ac- 
companying inflammation,  and,  after  remaining  for  some  time  in 
the  interstices  of  the  filamentous  tissue  of  the  part,  may  be  removed 
by  the  absorbent  property  of  the  capillaries  and  minute  veins. 
The  latter,  in  the  form  of  minute  amorphous  masses,  disposed  be- 
tween the  filamentous  fibres,  or  the  component  atoms  of  the  tissue, 
augments  its  volume,  and  the  space  which  it  occupies,  agglutinates 
contiguous  parts,  and,  eventually  contracting  and  becoming  con- 
solidated, increases  much  the  natural  consistence  and  density  of  the 
tissue  in  which  it  has  been  deposited.  In  this  manner  induration 


156 


GENERAL  AND  RATHOLOGICAL  ANATOMY. 


takes  place  in  the  subcutaneous  and  intermuscular  cellular  tissue 
after  an  abscess,  in  the  female  breast  or  male  testis,  and  the  liver 
of  both  sexes,  after  inflammation,  and  in  the  pulmonic  tissue  after 
an  attack  of  peripneumony.  In  the  glands  now  mentioned,  and 
even  in  the  prostate  gland,  inflammatoi’y  induration  has  been  re- 
peatedly mistaken  for  scirrhous  induration.  This  error  the  accu- 
rate pathologist  will  avoid.  Inflammatory  induration  occasionally 
disappears,  and  is  never  attended  with  acute  pain.  Scirrhous  in- 
duration never  disappears,  but  proceeds  to  disorganizing  softening, 
and  atomical  mortification,  and  is  always  attended  with  stinging 
darting  pain,  and  flushes  of  burning  heat. 

Along  with  the  state  of  induration,  the  textures  are  often  ren- 
dered brittle  and  lacerable.  This  is  seen  in  the  arteries,  the  ten- 
dons, and  the  bones. 

Yj.  Gangrene  or  Mortification.  This  is  much  less  frequent  than 
has  been  supposed.  It  may  occur  in  the  skin,  in  raucous  mem- 
branes, in  fibrous  structures,  especially  tendons,  in  bone,  in  carti- 
lage, and  in  the  substance  of  the  lungs.  In  dry  gangrene,  {necro- 
sis, ustilago,  mal  des  ardens,)  which  is  the  most  perfect  specimen  of 
the  death  of  parts.  It  affects  skin,  cellular  membrane,  muscle, 
tendon,  ligament,  artery,  vein,  periosteum,  bone,  and  cartilage  in- 
discriminately and  generally.  Its  anatomical  character  consists  in 
coagulation  of  the  blood  in  the  vessels,  always  the  capillary,  some- 
times the  larger  branches.  But  whether  tlfis  be  the  cause  or  the 
effect  of  the  death  of  the  parts  is  uncertain.  A fact  formerly  men- 
tioned regarding  the  influence  of  ossification  of  the  arteries  in  pro- 
ducing gangrene  of  the  toes,  feet,  and  legs  in  old  persons  would 
seem  to  show  that  it  is  the  cause.  The  phenomena  of  the  dry  gan- . 
grene,  or  that  produced  by  spurred  rye  and  bad  food,  on  the  other 
hand,  might  favour  the  notion,  that  coagulation  of  blood  is  the  ef- 
fect. The  gangrene  produced  by  tight  ligature,  and  in  the  case  of 
tumours,  may  be  referred  to  either  head. 

6.  Fever.  In  this  disease,  whatever  be  its  form,  intermittent, 
remittent,  or  continued,  the  capillary  vessels  are  the  principal  seat 
of  disorder.  Nor  is  the  affection  confined  to  the  capillaries  of  one 
region,  of  one  organ,  or  of  one  tissue.  The  seat  of  fever  is  to  be 
sought  neither  in  the  capillaries  of  the  brain  and  spinal  chord,  nor 
in  those  of  the  lungs,  nor  in  those  of  the  alimentary  canal,  but  it 

is  diffused  over  the  minute  ramifying  communications  of  the  aortic 

4 


SYSTEIM  OF  CAPILLARY  VESSELS,  &C. 


157 


and  venous  branches  in  whatever  part  of  the  body  these  communi- 
cations are  found.  To  establish  the  truth  of  this  statement,  it  is 
requisite  merely  to  consider  the  phenomena  of  fever  in  the  living 
body,  and  its  traces  and  effects  in  the  dead. 

a.  I presume  that  the  affection  of  the  capillary  system  of  the 
brain,  both  cranial  and  vertebral,  is  too  generally  admitted  to  re- 
quire being  formally  demonstrated.  In  point  of  fact,  the  pain  of 
the  head  in  the  beginning  of  all  fevers,  the  derangement  of  thought 
during  their  progress,  and  the  tendency  to  stupor,  and  absolute 
coma  towards  the  conclusion,  are  sufficient  alone  to  prove  disorder 
of  the  cerebral  capillaries.  But  when  blood  or  serous  fluid  is  found 
effused  into  the  ventricles,  when  the  vessels  of  the  brain  are  found 
turgid,  distended  with  blood,  and  more  numerous  than  natural,  it 
is  impossible  to  resist  the  inference  as  to  the  overloaded  state  of  the 
cerebral  capillaries  during  life.  I am  aware  that  cases  of  fever  are 
sometimes  adduced,  in  which  neither  pain  of  the  head  nor  deranged 
thought  are  observed.  I can  only  say,  that,  among  a very  great 
number  of  cases  which  I have  observed,  though  in  a few  the  pa- 
tient did  not  complain  of  headach,  it  was  always  possible  to  recog- 
nize more  or  less  derangement  of  thought. 

In  all  cases,  pain  is  felt  when  the  patient  coughs  or  stoops,  or 
when  the  head  is  slightly  shaken,  and  when  no  pain  is  said  to  be 
felt,  it  indicates  that  the  stage  of  natural  sensation  is  passed,  and 
that  he  complains  not,  because  be  does  not  feel. 

In  ague,  the  oppression  of  the  cerebral  capillaries  may  be  so 
great  as  to  constitute  inflammation  (Siriasis  j^gyptiaca,')  or  phre- 
nitic  ague,  or  in  various  degrees  the  sleepy  quotidian,  the  sleepy, 
lethargic,  hemiplegic,  carotic,  and  apoplectic  tertian,  and  the  co- 
matose quartan  of  practical  authors,  (Werlhof,  Torti,  Lautter, 
Morton,  Sydenham,  &c. ;)  the  same  disease  which  has  been  named 
by  Lancisi,  Baglivi,  and  IMorgagni,  epidemic  apoplexy.  (Apo- 
plexia  febricosa,  Cams febricosus.) 

Tbe  disorder  of  tbe  capillaries  of  the  spinal  chord  is  indicated 
by  pain  and  weight  in  various  parts  of  the  column,  by  the  derange- 
ment in  the  muscular  motions,  especially  local  palsy,  e.  g.  of  the 
arms,  legs,  &c.  by  the  tetanic  spasms  and  convulsions  taking  place 
in  many  fevers.  After  death,  much  serous  fluid  flows  from  the 
theca  ; the  vessels  of  the  chord  are  distended  and  numerous ; in 
all  instances,  serous  fluid  is  effused,  and  sometimes  pure  blood  is- 
sues from  its  capillaries. 


158 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


/3.  That  the  capillary  system  of  the  lungs  is  overloaded  and  op- 
pressed in  all  fevers,  is  one  of  the  most  certain  points  in  pathology. 
During  the  ague  fit,  the  respiration  is  invariably  quicker  than  na- 
tural, sometimes  to  the  amount  of  thirty  or  thirty-six  in  the  minute; 
the  patient  complains  of  a sense  of  weight  in  the  breast,  cannot 
breathe  fully,  pants,  and  has  frequent  cough.  In  continued  fever, 
the  respiration  is  invariably  quicker  and  more  laborious  than  na- 
tural, a deep  breath  cannot  be  drawn  easily,  and  more  or  less  sense 
of  oppression  and  weight  is  felt.  I have  found  the  respiration  in 
continued  fever  so  quick  as  thirty-six  in  the  minute,  while,  in  or- 
dinary cases,  the  application  of  the  stethoscope  indicates  an  embar- 
rassed state  of  the  circulation  in  the  pulmonary  capillaries.  In 
persons  predisposed,  expectoration  streaked  with  blood,  (Jicemoptoe,) 
is  not  unfrequent  during  continued  fever. 

The  same  conclusion  is  clearly  established  by  examination  of  the 
lungs  of  persons  cut  off  either  by  intermittent  or  by  continued  fe- 
ver. In  many  instances  of  the  former  it  induces  bronchial  inflam- 
mation, or  proceeds  to  actual  peripneumony  or  pleurisy,  constitut- 
ing the  catarrhal,  pneumonic,  or  pleuritic  tertian  respectively. 
(Werlhof,  Torti,  Lancisi,  &c.)  In  the  latter,  the  bronchial  mu- 
cous membrane  is  always  more  or  less  red,  sometimes  crimson  or 
purple,  or  of  a deep  brown  colour,  rough,  and  much  thickened ; 
the  submucous  tissue  is  brown  and  loaded  with  serous  fluid ; and 
the  minute  vessels  are  much  distended  with  dark-coloured  blood. 
The  bronchial  tubes  are  very  commonly,  in  fatal  cases,  perfectly 
filled  with  thick  viscid  mucus,  which  adheres  to  the  inner  surface 
of  the  bronchial  membrane.  The  serous  surface  of  the  organ  is 
generally  livid  or  marbled  from  this  cause ; but  the  pleura  itself 
is  not  much  changed,  save  from  bloody  serum  discharged  into  its 
cavity.  The  lungs  in  totality  are  generally  dense,  and  firmer  than 
in  the  natural  state. 

These  changes  arise  from  the  minute  ramifying  vessels  at  the 
termination  of  the  pulmonary  artery,  and  the  origins  of  the  pulmo- 
nary veins  being  unusually  loaded  with  blood.  As  they  are  more 
so  than  can  be  readily  affected  by  the  ordinary  quantity  of  air  ad- 
missible in  such  a state,  imperfect  respiration  and  undue  change  of 
venous  blood  contributes  powerfully  to  the  bad  symptoms  and  the 
unfavourable  termination  of  the  disease.  In  such  a state  of  the 
organs  of  respiration  the  bronchial  arteries  are  less  able  to  coun- 
teract the  bad  effects  of  imperfectly  respired  blood,  in  so  fiir  as  they 


SYSTEM  OF  CAPILLAKY  VESSELS,  &C.  159 

receive  from  the  aorta,  blood  which  has  not  been  suflBciently  arte- 
rialized. 

y.  In  the  capillary  system  of  the  chylopoietic  and  assistant  chylo- 
poietic  viscera  traces  of  the  same  condition  may  be  recognized,  both 
from  the  symptoms  during  life  and  the  appearances  after  death. 
In  these  organs  two  capillary  systems  may  be  distinguished,  a pri- 
mary and  a secondary  one.  The  primary  is  that  which  consists  of 
the  ultimate  divisions  of  the  splenic,  gastric,  and  duodenal  arteries, 
and  of  the  superior  and  inferior  mesenteric  arteries,  and  their  cor- 
responding veins,  which  afterwards  terminate  in  the  splenic  and 
superior  and  inferior  mesenteric  veins.  The  secondary  capillary 
system  is  that  which  results  from  the  union  of  the  minute  extremi- 
ties of  the  portal  vein,  and  of  the  hepatic  artery  with  those  of  the 
vencB  cavcB  hepaticce. 

It  is  unnecessary  to  dwell  on  the  proofs  of  the  loaded  state  of 
the  capillary  system  of  the  alimentary  canal.  It  is  sufficient  to 
remind  the  student  that  the  furred  or  brown  tongue,  the  thirst,  the 
sense  of  internal  heat,  the  loathing,  squeamishness,  and  sometimes 
sickness,  with  weight,  oppression,  and  tenderness  of  the  epigastric 
region,  sufficiently  demonstrate  the  morbid  state  of  the  capillaries 
of  the  oesophagus,  stomach,  and  duodenum  ; while  the  constipa- 
tion of  the  bowels  at  the  commencement,  insensibility  to  cathartic 
medicine  throughout,  and  occasional  looseness  at  the  conclusion, 
indicate  the  deranged  condition  of  those  of  the  intestines.  After 
death  the  minute  vessels  of  the  whole  of  these  parts  are  found  much 
distended  with  blood,  generally  dark-coloured.  (Hamilton,  Mills, 
Bateman,  Percival,  &c.) 

In  one  form  of  fever,  the  abdominal  or  intestinal  typhus,  the  ileum 
and  its  mucous  follicles,  are  very  much  affected.  The  follicles  be- 
come enlarged,  elevated,  and  prominent,  and  swelled  in  consequence 
of  their  proper  tissue  being  attacked,  and  perhaps  their  secreting 
pores  being  obstructed.  The  apices  become  dead,  and  are  thrown  off 
in  the  form  of  sloughs ; and  in  their  place  are  left  small  ulcers,  which 
in  no  long  time  enlarge,  spread,  and  increase  in  depth.  These 
changes  may  take  place  either  in  the  isolated  follicles  or  in  the  ag- 
gregated patches,  or  in  both  orders  of  glands.  They  shall  be  con- 
sidered more  fully  under  the  proper  head. 

In  certain  forms  of  fever  there  are  pain,  distension,  and  uneasy 
sensations  in  the  right  iliac  region ; and  when  percussion  is  em- 
ployed, the  sound  emitted  is  dull,  while  a peculiar  croaking  noise 


160 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


is  heard,  and  a gm’gling  movement  is  felt  beneath  the  fingers,  as  if 
produced  by  air  and  liquid  moving  within  the  intestine.  These  symp- 
toms continue  the  greater  part  of  the  duration  of  the  fever  ; and 
though  they  are  abated  by  local  depletion,  by  means  of  leeches  and 
the  use  of  laxative  medicines,  they  do  not  disappear  until  the  fever 
itself  either  abates  or  altogether  retires. 

The  portal  vein  constitutes,  among  the  vessels  of  the  digestive 
organs,  a secondary  capillary  system,  in  which  the  blood  is  not  less 
accumulated  than  in  the  primary  one.  It  may  be  thought,  that,  as 
the  blood  is  accumulated  in  the  first,  it  ought  not  so  readily  to  find 
its  way  into  the  trunk,  branches,  and  ramifications  of  the  second. 
But  this  objection  will  vanish,  when  it  is  remembered  that  at  the 
same  time  both  the  primary  and  the  secondary  system  of  capillaries 
become  overloaded.  This  state  of  the  capillaries  of  the  portal  and 
hepatic  system  is  established  by  the  appearance  of  the  liver  in  per- 
sons cut  off  by  fever. 

The  spleen  may  suffer  so  much  from  this  capillary  distension  as 
to  resemble  a mass  of  clotted  blood  without  trace  of  organization. 

This  morbid  and  extraordinary  distension  of  the  primary  and 
secondary  capillary  systems  of  the  chylopoietic  organs,  though  dis- 
tinct enough  in  the  fevers  of  temperate  countries,  is  most  conspicu- 
ously demonstrated  in  the  agues  and  remittents  of  warm  climates, 
and  especially  in  the  severe  and  exquisite  form  termed  yelloro  fever. 
In  the  former  great  sickness  and  epigastric  tenderness,  with  more 
or  less  vomiting,  are  frequent,  and  in  the  latter  constant  symptoms. 
The  vomiting,  nevertheless,  is  not  bilious,  as  has  been  too  generally 
imagined.  It  is  at  the  commencement  always  a watery  fluid,  evi- 
dently derived  from  the  capillaries  of  the  gastric,  and  perhaps  the 
duodenal  mucous  membrane.  (Dr  John  Hunter,  Jackson,  &c.) 
After  some  time  it  begins  to  be  mixed  with  bile,  expressed  in  all 
probability  from  the  gall-bladder  by  the  pressure  of  the  stomach  in 
the  act  of  vomiting.  A much  more  uniform  occurrence,  however, 
if  the  disease  does  not  subside  spontaneously,  or  is  checked  by  art, 
is  the  gradual  admixture  of  blood  somewhat  darkened  with  the  wa- 
tery fluid.  This  blood  issues  from  the  capillaries  of  the  gastric  and 
intestinal  tissues  by  a process  analogous  to  exhalation  in  the  sound 
state,  but  differing  in  so  far  as  in  the  capillaries,  from  which  it  pro- 
ceeds, a degree  of  disorganization  has  taken  place.  As  the  blood 
escapes  into  the  cavity  of  the  canal  originally  not  highly  scarlet,  it 
is  rapidly  blackened  by  the  action  of  the  carbonic  acid  and  sulphu- 


SYSTEM  OF  CAPILLAEY  YESSELS,  &C. 


161 


retted  hydrogen  gases,  at  all  times  present  in  greater  or  less  quan- 
tity. This  bloody  exudation  is  at  first  scanty,  but  gradually  in- 
creases as  the  disease  goes  on,  until  it  constitutes  the  greater  part 
of  what  is  discharged  both  by  vomiting  and  by  stool.  In  the  for- 
mer case  it  forms  the  black  vomit,  (vomito  prieto,)  or  coffee-ground 
matter,  so  frequent  in  fatal  cases  of  remittent  or  yellow  fever.  In 
the  latter  it  forms  the  dark,  tarry,  or  treacle-like  stools  mentioned 
by  practical  authors  in  the  same  disease.  (Jackson,  Hunter,  Phy- 
sic, Cathrall,  Bancroft,  &c.) 

The  description  now  given  is  general,  and  applies  to  this  capil- 
lary disorganization,  as  it  takes  place  both  in  bad  agues  and  remit- 
tents, and  in  yellow  fever.  In  the  former  it  is  less  frequent,  but 
nevertheless  takes  place  sufficiently  often.  In  the  latter  it  is  seen 
in  its  most  exquisite  form,  and  is  almost  invariable  in  fatal  cases. 
Its  origin  and  formation  have  been  traced  in  the  most  satisfactory 
manner  by  repeated  dissections. 

The  idea  of  black  vomit  being  morbid  or  vitiated  bile  deserves 
no  attention.  In  some  instances  of  severe  yellow  fever  a dark-co- 
loured fluid  of  the  same  physical  characters  as  those  found  in  the 
intestinal  tube,  may  be  traced  coming  down  the  biliary  and  hepatic 
duct  from  the  pori  hiliarii.  This,  however,  instead  of  being  bile,  is 
blood  which  has  oozed  from  the  hepatic  capillaries  in  the  same 
manner  as  that  from  the  intestinal  ones. 

h.  The  capillaries  of  the  urinary  system  are  much  affected  dim- 
ing fever.  Both  in  intermittents  and  in  continued  fevers  bloody 
urine  has  been  discharged. 

£.  In  the  same  manner  the  capillaries  of  the  muscles,  of  the  fila- 
mentous tissue,  and  of  the  skin  are  morbidly  distended.  One  of 
the  most  common  symptoms  of  fever  is  pain,  soreness,  and  a sense 
of  bruising  in  the  muscular  parts  and  limbs  in  general.  In  fatal 
cases,  when  these  parts  are  examined  by  incision,  unusual  vascular 
distension  and  extravasation  of  blood  are  frequently  seen.  The 
livid  spots  and  patches,  {molopes  ; vibices  ; ecchymomata)  are  proofs 
of  the  same  state  of  the  capillaries  of  the  filamentous  tissue,  as  pe- 
techial eruptions  denote  this  in  the  skin. 

In  short,  there  is  scarcely  a texture  or  organ  of  the  animal  body, 
the  capillaries  of  which  are  not  disordered  in  the  different  forms  of 
fever ; and  this  disorder,  instead  of  being  confined  to  the  capilla- 
ries of  a single  organ,  is  extended  throughout  the  capillary  system 
at  large. 

n 


162 


GENEKAL  AND  PATHOLOGICAL  ANATOMY. 


It  is  doubtless  true  that  in  individual  cases  this  disorder  may  be 
greater  and  more  distinct  in  one  set  of  capillaries  than  in  another. 
In  one  set  of  patients  the  capillaries  of  the  brain  may  appear  to  be 
most  disordered ; in  another  those  of  the  lungs ; in  a third  those 
of  the  intestinal  canal ; and  in  a fourth  those  of  the  urinary  organs. 
It  is  always  found,  however,  in  such  cases,  that  the  affection  of  one 
organ  does  not  entirely  exclude  that  of  another ; and  while  the  ca- 
pillaries of  the  one  are  very  much  affected,  though  those  of  the 
others  are  less  so,  they  are  by  no  means  in  the  healthy  state.  In 
all  cases  of  severe  and  exquisite  fever,  whether  intermittent,  re- 
mittent, or  continued,  the  capillaries  of  the  brain,  of  the  lungs  and 
heart,  of  the  chylopoietic  organs,  of  the  urinary  organs,  of  the 
muscles,  of  the  cellular  tissue,  and  of  the  skin,  are  affected  nearly 
in  the  same  degree.  (Macartney,  Cooke,  &c.) 

An  important  question  is  to  ascertain  the  precise  nature  of  this 
affection.  The  dissections  of  Pringle,  Ilome,  Ploucquet,  Mills, 
&c.  as  to  the  brain,  those  of  Schenck,  Morgagni,  Lieutaud,  Sar- 
coni,  and  others,  as  to  the  thoracic  organs,  and  those  of  Lieutaud, 
Petit  and  Serres,  Broussais,  Lerminier  and  Andral,  Louis,  Cho- 
mel,  and  Bright,  as  to  the  intestinal  canal,  might  favour  the 
supposition  that  the  morbid  process  of  fever  consists  in  inflam- 
mation. Against  this  conclusion,  however,  various  facts  and 
arguments  may  be  adduced.  Isit,  In  fatal  cases  of  fever  unequi- 
vocal traces  of  inflammation  are  not  uniformly  or  invariably  found. 
The  proportion  in  which  these  marks,  as  albuminous  effusion,  sup- 
puration, ulceration,  &c.  are  observed,  is  small  compared  with  the 
number  in  which  accumulation  of  blood  in  the  capillaries,  and  more 
or  less  disorganization  of  these  vessels  are  observed.  2d,  In  cases 
of  pure,  genuine,  and  unmixed  inflammation  of  the  internal  or- 
gans, whether  spontaneous  or  from  injury,  the  concomitant  symp- 
toms, though  febrile,  are  totally  different  from  those  which  distin- 
guish either  intermittent  or  continued  fever.  2>d,  The  marks  or 
effects  of  inflammation  which  are  found  in  the  bodies  of  persons 
cut  off  by  fever  are  accidental  complications,  and  may  almost  in- 
variably be  traced  to  inflammatory  reaction  supervening  on  the  fe- 
brile process,  in  consequence  either  of  the  physical  peculiarities  of 
the  individual,  the  local  weakness  of  the  parts,  or  the  influence  of 
external  morbific  causes.  4<7i,  Inflammation  is  a local  action  con- 
fined to  the  capillaries  of  one  tissue,  or  at  most  of  one  organ  and 
contiguous  tissues ; and  while  the  structure  and  functions  of  the 

3 


SYSTEM  OF  CAPILLAEY  VESSELS,  &C. 


163 


organ  may  be  completely  impaired,  those  of  others  remain  un- 
altered. In  fever,  on  the  contrary,  the  capillaries  of  all  the  tissues 
and  of  every  organ  are  affected  ; and  while  no  individual  organ  is 
much  affected  at  the  commencement,  every  organ  suffers  a little  in 
the  general  disorder  of  the  capillary  system.  5th,  Inflammation 
gives  rise  to  albuminous  exudation,  suppuration,  ulceration,  and  in 
certain  parts  to  serous  or  sero-purulent  effusion.  In  fever  the 
morbid  state  of  the  capillaries  terminates  in  complete  destruction 
or  disorganization  of  their  organic  extremities,  and  the  consequent 
oozing  of  blood  from  the  surface  of  the  several  membranes  and  or- 
gans. 

In  conclusion,  though  it  may  be  regarded  as  established,  that 
during  the  morbid  process  of  fever  the  w’hole  capillary  system  is 
unduly  distended  and  loaded  with  an  inordinate  quantity  of  blood, 
which  really  moves  more  slowly  and  imperfectly  than  during  health, 
we  have  no  facts  which  enable  us  to  determine  wbat  induces  this 
peculiar  and  excessive  accumulation.  Much  has  been  lately  said 
of  congestion,  and  especially  venous  congestion.  The  state  of  the 
capillary  system  which  I have  attempted  to  describe  is  that  of  con- 
gestion or  accumulation ; and  so  far  the  hypothesis  of  congestion 
is  intelligible.  Of  the  existence  of  venous  congestion,  however, 
unless  as  an  effect  of  that  in  the  capillary  vessels,  there  is  neither 
proof  nor  probability.  It  is  not  a primary  but  a secondary,  or 
rather  remote  consequence.  (Marsh.) 

■n.  Changes  in  the  blood  in  Fever.  {Hcematopathia.)  An- 
other question  belonging  to  a different  head,  nevertheless,  in  this 
place  may  deserve  some  consideration  in  explaining  this  uni- 
versal affection  of  the  vascular  system.  This  is  the  state  of  the 
blood  itself,  and  to  what  extent  and  in  what  manner  it  influences 
the  formation  of  these  phenomena  of  deranged  action  in  the  vascu- 
lar system.  Though  this  has  been  already  in  part  noticed  under 
the  head  of  the  blood,  yet  it  may  render  the  pathological  views 
on  fever  more  complete  and  more  intelligible  to  advert  shortly  to 
certain  facts  on  the  subject  in  this  place,  and  the  necessary  infe- 
rences from  these  facts. 

All  observers  agree  in  representing  the  blood  to  be  more  or  less 
changed  in  its  properties  and  constitution  in  tbe  different  varieties  of 
fever,  whether  intermittent,  remittent,  or  continued.  To  the  princi- 
pal views  of  the  old  pathologists  it  is  unnecessary  to  advert.  But  by 
all  observers  during  the  18th  century,  when  it  was  supposed  import- 


164 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


ant  to  attend  much  to  the  state  of  the  blood  and  its  appearances,  it 
is  commonly  described  as  dissolved,  and  deficient  in  crasis. 

What  this  dissolved  state  consists  in  we  are  not  informed  ; neither 
do  we  at  present  possess  means  of  knowing.  In  many  of  the  con- 
tinental schools,  however,  the  term  dyscrasia  of  the  blood  has  been 
and  is  now  employed  to  express  a morbid  state  of  that  fluid. 

The  following  facts,  which  I have  repeatedly  observed  in  conti- 
nued fever,  appear  to  me  deserving  attention. 

If  a person  attacked  with  fever  (synochus  or  typhus,)  be  blooded 
at  the  commencement  of  the  attack  or  within  three  or  four  days  there- 
from,The  blood  coagulates  very  much  in  the  usual  time,  and,  with 
a moderately  firm  coagulum,  shows  an  average  proportion  of  serum. 
If  in  a person  labouring  under  fever  blood  be  drawn  about  six  or 
seven  days  after  the  commencement  of  the  symptoms,  it  coagulates 
more  slowly,  and  less  perfectly.  The  coagulum  is  loose  and  soft, 
and  the  quantity  of  serum  small.  If  blood  be  drawn  at  a period 
still  later  in  the  disease,  the  coagulum  is  yet  more  loose  and  soft, 
and  the  serum  still  smaller  in  quantity.  In  the  majority  of  cases 
of  fever  at  this  stage,  the  serum  sometimes  does  not  exceed  one 
drachm,  or  at  most  two,  and  in  some  cases  no  serum  at  all  is  sepa- 
rated. At  the  same  time,  the  coagulum  is  soft,  flaccid,  tremulous, 
and  when  divided,  evidently  consists  of  the  coagulum,  properly  so 
called,  and  the  serum  involved  and  retained  within  the  clot.  This 
I have  seen  so  often,  and  after  trials  made  with  attentive  observa- 
tion of  the  fact,  that  I cannot  doubt  its  accuracy  as  a general  fact. 

The  conclusion  which  I conceive  naturally  flows  from  the  facts 
now  stated,  is,  that  in  fever  the  coagulating  power  of  the  blood  is 
progressively  impaired  in  the  course  of  the  disease,  and  it  may  in 
extreme  cases  he  altogether  gone.  The  quantity  of  serum  produc- 
ed is  in  general  in  the  direct  ratio  of  the  coagulating  power.  If 
the  blood  coagulates  vigorously  and  energetically,  the  serum  is  ex- 
pressed from  it  in  large  quantity.  If  the  serum  is  separated  in 
small  quantity,  it  shows  not  that  little  serum  is  in  the  blood,  but 
that  the  coagulating  power  being  impaired  and  weakened,  it  does 
not  force  the  serum  out  of  the  fibrin  in  due  quantity.  When  no 
serum  appears  at  all,  it  shows  that  the  coagulating  power  is  so  far 
destroyed,  that  it  is  unable  to  separate  the  blood  into  clot  and 
serum. 

That  this  loss  of  coagulating  power  in  the  blood  takes  place  in 
fever,  and  increases  gradually  as  the  disease  advances,  is  rendered 

4 


SYSTEM  OF  CAPILLARY  VESSELS,  &C. 


165 


certain,  not  only  by  the  facts  now  stated,  but  by  tbe  condition  of 
the  blood  found  in  the  vessels  after  death.  That  fluid  is  then 
found  filling  the  arteries,  as  well  as  the  veins,  not  scarlet,  but 
of  a dark-brown  colour,  and  viscid,  grumous,  and  very  imperfectly 
coagulated. 

There  appear,  therefore,  here,  two  remarkable  circumstances ; 
one,  the  diminution  or  loss  of  coagulating  power ; the  other  the  di- 
minution or  loss  of  arterialization. 

What  is  the  cause  of  these  changes  ? It  is  reasonable  to  think 
that  for  this  cause  we  ought  to  look  chiefly  in  the  lungs.  The 
lungs,  I have  already  observed,  are  in  all  cases  of  fever  more  or 
less  disordered,  their  vessels  are  congested  and  oppressed ; their  ac- 
tion is  impaired ; and  there  is  proof  of  great  derangement  in  the 
action  of  the  bronchial  membrane,  imperfect  admission  of  air  to 
the  bronchial  tubes  and  their  membrane,  and,  accordingly,  inade- 
quate arterialization,  or  it  may  be  the  lowest  possible  degree  of 
that  function.  These  may  be  regarded  as  matters  of  fact,  capable 
of  demonstration.  Does  this  morbid  state  of  the  blood,  then,  begin 
in  the  lungs,  or  in  some  other  part,  or  set  of  vessels  ? When  we 
consider  the  large  extent  of  the  bronchial  membrane,  the  fact  that 
upon  it  are  ramified  the  capillary  divisions  of  the  pulmonary  ar- 
tery and  veins  ; the  fact  that  through  these  vessels  passes  the  whole 
blood  of  the  body,  and  the  further  fact  of  the  manifest  disorder  of 
the  whole  blood  of  the  system  in  fever,  it  is  impossible  to  resist  the 
conclusion,  that  it  must  be  chiefly,  perhaps  solely,  on  the  blood  of 
the  lungs,  that  the  cause  of  fever  begins  to  display  its  primary  and 
initial  operation. 

On  the  nature  of  tliis  cause  it  is  not  possible  to  speak  with  con- 
fidence or  certainty.  But  if  the  general  opinion,  that  it  is  a poi- 
son difiused  through  the  air,  be  well  founded,  it  is  not  difficult  to 
perceive  at  least  some  traces  of  its  mode  of  operation.  YVhether 
that  poison  be  extricated  in  the  form  of  a vapour  or  exhalation 
from  the  surface  of  the  earth,  and  is  telluric  in  origin  ; or  is  elimi- 
nated from  vegetable  matters  in  certain  circumstances  of  decay  or 
change;  or  from  vegetable  and  animal  matters  conjoined;  or  is 
given  oflP  as  a subtile  effluvium  from  the  bodies  of  living  human 
beings,  in  circumstances  unfavourable  to  ventilation  and  the  healthy 
performance  of  the  functions ; or  is  the  result  of  some  unknown  and 
unappreciable  state  of  the  atmosphere  ;— it  must  equally  be  inhaled 
with  the  air  in  inspiration,  and  thus  thoroughly  mixed  with  the 


166 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


blood  of  the  lungs  in  successive  acts  of  the  function  of  respiration. 

If  it  be  so  mixed,  it  must  be  circulated  with  the  circulating  blood, 
and  in  this  manner  distributed  through  the  whole  vascular  system 
to  every  organ  of  the  body.  In  doing  so,  however,  this  poisonous 
material  must  have  so  altered  the  blood  in  the  lungs,  as  to  produce 
in  that  blood  and  in  these  organs  a more  decided  effect  than  else- 
where. The  shock  first  inflicted  on  the  blood  in  these  organs  ap- 
pears, it  is  natural  to  think,  the  great  cause  of  the  loss  of  coagu- 
lating power  and  the  impaired  arterial ization.  We  know  that  one 
of  the  great  uses  of  the  lung  next  to,  or  along  with  the  arteriali- 
zation  of  the  blood,  is  to  maintain  the  coagulating  power,  and  to 
restore  it  when  impaired.  It  is,  therefore,  natural  to  infer,  that 
when  the  coagulating  power  is  diminished,  it  depends  on  some  im- 
pediment to  the  function  of  respiration,  and  that  when  the  function 
of  respiration  is  imperfectly  performed,  that  should  evince  its  effects 
in  a diminished  proportion  of  coagulating  power. 

If  these  views  be  well  founded,  it  follows,  that,  when  the  blood 
thus  altered  is  circulated,  however  imperfectly,  it  must  operate 
hurtfully  on  the  organs  to  which  it  is  transmitted.  It  must  act,  in 
truth,  as  a poison ; and  many  of  the  phenomena  of  fever  are  similar, 
certainly,  to  the  effects  of  poison,  especially  a poison  at  first  irritant, 
and  then  sedative  and  narcotic.  This  appears  to  be  the  mode  in 
which,  towards  the  latter  stage  of  fever,  its  cause  acts  on  the  brain 
and  spinal  marrow. 

7.  Hemorrhage.  In  all  cases  of  Hemorrhage,  whether  by  rup- 
ture or  by  exhalation,  the  capillaries  are  unusually  loaded  with 
blood.  This  is  established  by  the  appearance  of  the  brain  in  apo- 
plexy, of  the  lung  in  hemoptysis.!  (pulmonary  apoplexy  of  Laennec,) 
pneumonorrhagia  of  Frank  and  Latour,  of  the  prostate  gland  in 
chronic  enlargement,  (Home,)  and  the  state  of  the  mucous  surfaces 
in  general.  In  the  two  first  cases,  especially  in  that  of  the  lungs, 
the  pulmonic  capillaries  are  large,  numerous,  and  distended  with 
blood,  the  pulmonic  tissue  more  or  less  injected  and  firm,  and  blood 
is  found  oozing  from  the  surface  of  the  bronchial  membrane.  ( Stark 
and  Laennec.)  With  this,  however,  is  conjoined  a friable  or  la- 
cerable  and  imbrowned  state  of  the  bronchial  membrane  and  pul- 
monic tissue. 

8.  Excess  of  Nutrition.  {Hypertrophia.')  Hypertrophic  aug- 
mentation. That  every  unusual  increase  in  the  size  of  parts  is  to 
be  ascribed  to  the  agency  of  the  capillaries  is  well  established  by 


SYSTEM  OF  CAPILLAEY  VESSELS,  &C. 


' 167 


the  phenomena  of  morbid  enlargements  and  preternatural  growths. 
Every  instance  of  unusual  or  anormal  size  is  of  three  kinds. 

a.  A texture  or  organ  becomes  enlarged  in  consequence  of  a 
uniform  increase  of  its  proper  organic  substance.  Thus  the  heart 
becomes  thicker,  firmer,  and  larger  in  all  its  dimensions.  Its  mus- 
cular substance,  and  perhaps  the  intermuscular  filamentous  tissue, 
are  actually  augmented.  They  are  redder,  firmer,  and  contain 
more  blood  than  natural ; and  their  blood-vessels  are  increased  in 
size  and  number.  The  bladder  in  like  manner  undergoes  the  same 
change ; and  in  its  thickened  and  indurated  tissue  also  dissection 
shows  a more  copious  supply  of  blood,  and  a more  abundant  distri- 
bution of  vessels  than  in  the  natural  state. 

Of  this  preternatural  increase  of  bulk  and  density  the  capillaries 
of  the  organs  are  the  sole  agents.  In  some  instances  this  hyper- 
trophy appears  to  be  of  the  nature  of  a chronic  process  of  inflam- 
mation. This  is  exemplified  in  the  case  of  the  liver,  the  testicle, 
the  prostate  gland,  the  female  breast,  and  even  the  heart. 

/3.  Any  individual  texture  may  undergo  a preternatural  or  anor- 
mal enlargement  by  local  deposition  of  matter  similar  to  itself. 
Thus  a bone  may  become  enlarged,  as  in  exostosis ; a gland  may 
become  enlarged,  as  in  various  instances  the  testicle  and  the  female 
breast  do.  That  the  skin  is  liable  to  a particular  species  of  hyper- 
trophic augmentation  is  well  ascertained  from  cases  given  by  many 
authors,  but  especially  from  one  recorded  by  Mr  John  Bell.*  In 
mucous  membrane,  lymphatic  gland,  and  secreting  glands,  similar 
local  augmentations  take  place. 

y.  In  any  tissue  or  organ  a deposition  of  new  matter  altogether 
foreign  to  that  tissue  may  take  place.  This  new  matter  may  be 
either  similar  to  that  of  some  natural  tissue  of  the  animal  body ; 
for  example,  it  may  be  serous  membrane,  or  bone,  or  cartilage ; 
or  of  a nature  entirely  dissimilar,  and  never  seen  unless  in  the  mor- 
bid state ; for  instance,  the  several  varieties  of  tubercular  deposi- 
tion of  scirrhous  deposition,  of  fungoid  deposition,  and  several  of 
the  forms  of  sarcoma  enumerated  by  Mr  Abernethy. 

In  whatever  mode  these  new  productions  vary  in  intimate  struc- 
ture, all  agree  in  being  connected  with  more  or  less  augmented 
development  of  the  capillary  system.  In  many  the  growth,  if  not 
the  origin,  can  be  traced  to  the  increased  number,  or  at  least  en- 
larged size,  of  the  capillary  arteries.  In  most  of  these  tumours 
* Principles  of  Surgery,  Vol.  III.  Discourse  ii.  Case  of  Eleanor  Fitzgerald. 


168 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  vessels  are  large,  numerous,  and  well  filled  with  blood  ; and  if 
divided  in  the  living  body  they  are  the  source  of  abundant  hemor- 
rhage. In  some  instances  these  vessels  penetrate  from  the  adjoin- 
ing tissue  all  round  the  tumour  in  the  form  of  numerous  minute 
arteries,  which  afterwards  are  ramified  in  the  tumour.  In  others, 
which  are  perhaps  more  numerous,  they  enter  at  one  point  in  the 
shape  of  three  or  four  large  trunks,  which  are  afterwards  divided 
in  the  substance  of  the  growth. 

As  these  new  or  foreign  growths,  therefore,  are  known  to  abound 
in  capillaries,  it  is  inferred,  that,  if  this  abundance  of  vessels  be  not 
the  direct  cause,  they  furnish  the  materials  of  growth.  The  diffi- 
culty in  the  theory  of  their  formation  is  to  ascertain  the  circum- 
stances which  first  determine  this  local  development  of  the  capillary 
system.  In  some  instances  it  can  be  distinctly  traced  to  mechani- 
cal injury,  (John  Bell  and  Abernethy.)  After  a bruise,  for  exam- 
ple, blood  and  lymph  being  poured  forth,  instead  of  being  absorbed, 
become  penetrated  with  vessels,  which  conversely  are  stimulated 
by  the  presence  of  this  substance  to  convey  more  blood,  and  thus 
enlarge  in  size.  In  others  this  local  capillary  development  com- 
mences without  obvious  cause.  Upon  the  whole,  the  growth  of 
tumours  is  to  be  viewed  as  the  result  of  an  aberration  or  anorraal 
action  of  the  usual  nutritive  process  to  which  the  capillary  vessels 
are  subservient.* 

The  theory  of  tumours  or  morbid  growths  depending  on  inor- 
dinate local  development  of  the  capillary  system  was  understood 
by  Valsalva,  Morgagni,  Pohl,  and  others,  but  was  first  fully  illus- 
trated by  John  Bell  and  Mr  Abernethy, f and  afterwards  by  Sir 
Everard  Home  and  Mr  Macilwain. 

* “ As  wounded  parts  are  healed  by  adhesion,  so  are  dilated  or  strained  parts  by  in- 
creased nutrition.” — “ Tumour  and  various  modifications  of  disease  follow  fi-om  the 
same  law  of  vascular  action  and  nutrition  which  maintained  health.  If  each  indivi- 
dual vessel,  whether  artery  or  vein,  have  its  coats  thickened  by  dilatation  or  partial 
laceration,  the  same  must  be  presumed  of  each  minuter  vessel  in  the  distended  womb, 
of  each  lesser  vein  and  petty  artery  in  a piece  of  distended  skin,  or  in  a diseased  gland. 
The  enlargement,  then,  of  each  blood-vessel  by  deposition  of  nutritious  matter  along 
its  sides  makes  not  a mere  distension  of  vessels,  but  a solid  and  permanent  bulk.  The 
more  vessels  are  enlarged  consistently  with  their  healthy  action,  the  more  particles  are 
they  able  to  secrete  ; whence  the  increment  of  tumours  is  perpetually  accelerating 
unless  when  opposed  by  peculiar  causes.” — The  Principles  of  Surgery,  by  John  Bell, 
Surgeon.  Vol.  III.  Discourse  ii. 

-f-  An  Attempt  to  form  a Classification  of  Tumours  according  to  their  Anatomical 
Structure,  by  John  Abernethy.  London,  1811, 


ERECTILE  TISSUE. 


169 


CHAPTER  VIII. 

ERECTILE  TISSUE, — ( Vasa  Erigentia, — Vascula  Erectiha, — 
Tissu  Erectile. 

Section  I. 

The  peculiar  arrangement  of  vessels  constituting  the  erectile 
tissue  was  very  early  anticipated  by  our  countryman  William 
Cowper,  who  states,  that  he  demonstrated  the  direct  communication 
of  arterial  and  venous  canals,  not  only  in  the  lungs,  but  in  the 
spleen  and  penis,  “ in  which,”  says  he,  ‘‘  I have  found  these  com- 
munications more  open  than  in  other  parts.”* 

The  system  of  capillary  arteries  and  veins  does  not  present  the 
same  arrangement  in  all  situations  or  in  all  the  tissues  of  the  human 
body.  Among  the  terminations  of  arteries  enumerated  by  Haller, 
one  which  he  referred  to  the  head  of  exhalants  was  that  of  a red 
artery  or  arteries  pouring  their  blood  into  the  spongy  or  cellular 
structure  of  the  cavernous  bodies  of  the  nipple,  the  clitoris,  and 
the  penis,  that  of  the  wattles  of  the  turkey,  and  the  comb  of  the 
cock.f  His  detailed  examination  of  these  parts  shows,  that,  with  a 
correct  knowledge  of  their  anatomical  structure,  he  had  not  a very 
distinct  conception  of  the  manner  in  which  their  vesels  are  dis- 
posed. 

Bichat  remarked  that  the  spleen  and  the  cavernous  body  of  the 
penis,  instead  of  presenting,  as  the  serous  surfaces,  a vascular  or 
capillary  net-work,  (i-eseaii  vasctdaire,)  in  which  the  blood  oscillates 
in  different  directions  according  to  the  impulse  which  it  receives, 
exhibit  only  spongy  or  lamellar  tissues,  still  little  known  in  their 
structure,  in  which  the  blood  appears  often  to  stagnate  instead  of 
moving.  As  this  peculiar  structure  was  known  in  the  cavernous 
body  to  be  the  seat  of  a motion  long  known  by  tbe  name  of  erec- 
tion., MM.  Dupuytren  and  Richerand  distinguished  this  arrange- 
ment of  arteries  and  veins  as  a peculiar  tissue,  under  the  name  of 
erectile, — a distinction  which,  though  partly  understood  before, 
nas  only  now  been  admitted  as  well-founded  in  the  writings  of 
anatomical  authors.  According  to  the  arrangements  of  M.  Bec- 
lard,  this  tissue  comprehends  not  only  the  structure  of  the  ca- 

* Philosophical  Transactions,  Vol.  XXIII.  No.  285,  p.  1386.  1703. 

-}•  Elementa,  Lib.  ii.  sect.  I.  sect.  24.  III.  p.  102. 


170 


GENERAL  AND  rATHOLOGICAL  ANATOMY. 


vernous  body,  but  that  of  the  spongy  substance,  {corpus  spongio- 
sum,') which  encloses  tbe  urethra,  and  forms  its  two  extremities, 
the  bulb  and  gland,  the  clitoris,  the  nymplice,  and  the  nipple  of  the 
female,  the  structure  of  the  spleen  in  both  sexes,  and  even  that 
of  the  lips.* * * §  Some  are  disposed  to  add  the  structui’e  of  the  iris, 
and  the  peculiar  plexiform  network  of  vessels  in  the  vagina  of  the 
female. 

It  is  somewhat  unfortunate  that  the  researches  of  anatomists  on 
this  erectile  tissue  have  been  restricted  chiefly  to  the  spongy  body 
of  the  urethra  and  the  cavernous  body  of  tbe  penis ; and  it  is  ra- 
ther by  analogy  than  very  direct  proof,  that  similarity  of  structure 
between  them  and  the  other  parts  referred  to  the  same  head  is 
maintained.  I shall  state  here  what  is  most  satisfactorily  known 
on  the  subject. 

The  cavernous  body  of  the  urethra,  or  what  is  now  termed  its 
spongy  hody,\  is  represented  by  Haller  to  consist  of  fibres  and 
plates  issuing  from  the  inner  surface  of  the  containing  membrane, 
and  mutually  interlacing,  so  as  to  form  a series  of  communicating 
cells,!  into  which  the  proper  urethral  arteries  pour  their  blood  di- 
rectly during  the  state  of  erection.  § 

The  cavernous  body  of  the  penis  is  in  like  manner  represented 
to  be  a part  of  a spongy  nature,  or  to  consist  of  innumerable  sacs 
or  cells  separated  by  plates  and  fibres,  which,  at  the  moment  of 
erection,  are  distended  with  blood  poured  from  the  arteries,  and 
which  was  afterwards  removed  by  some  absorbing  power  of  the 
veins. 

This  opinion,  which  was  that  of  many  subsequent  anatomists, 
even  Bicbat  himself, ||  was  derived  apparently  from  the  facility  with 
which  the  blood  so  deposited  escapes,  not,  as  it  was  believed,  from 
divided  vessels,  but  from  areola,  or  interlaminar  spaces.  It  ap- 
pears, however,  to  have  been  at  variance  with  what  had  been  an- 
ciently taught  by  Vesalius,  Ingrassias,  and  Malpighi,  and  more 
positively  stated  regarding  these  vessels  by  Hunter ; and  modern 

* Additions  a I’Anatomie  Generate  de  Xav.  Bichat,  par  P.  A.  Bedard,  p.  118. 

t Haller  applies  the  name  of  cavernous  tody  not  only  to  the  structure  of  the  penis, 
but  to  that  of  the  urethra. — Elem.  Lib.  xxvii.  Sect.  1 . 

J Elementa  Physiologise,  Lib.  xxvii.  sect.  1,  § 33. 

§ “ Sed  et  in  pene,  et  in  chtoride,  et  in  papilla  mammse,  et  in  collo  galli  indici, 
nimis  manifestum  est,  vemm  sanguinem  effundi,  neque  unquam  ejus  color  totus  de  iis 
partibus  evanescit,  quae  ab  effuso  sanguine  turgere  solent.” — Elementa,  Lib.  xxvii.  sect: 
3,  § 10. 

II  Systeme  Absorbant,  § 3,  p.  S98. 


ERECTILE  TISSUE. 


171 


researches  have  shown  it  to  be  completely  erroneous.  Cuvier  and 
Ribes  in  France,  Mascagni,  Paul  Farnese,  Moreschi  in  Italy,  and 
Tiedemann  in  Germany,  have  shown  that  there  are  no  cells  or 
spongiform  structure  in  the  erectile  tissue  of  the  cavernous  body. 

The  first  correct  view  of  the  structure  of  parts  of  this  description 
in  the  human  subject  was  given  by  Mascagni  in  his  account  of  the 
arterial  and  venous  communications  in  the  Spongy  Body  of  the 
Urethra.  In  1787  he  announced  in  his  work  on  the  Lymphatics, 
that  the  parts  called  cavernous  bodies,  both  in  the  penis  and  in  the 
clitoris,  were  simply  fasciculi,  or  accumulations  of  arterial  and  ve- 
nous vessels  without  interruption  of  canal ; but  that  between  the 
arteries  and  veins  of  the  spongy  bodies  a dilated  cavity  or  minute 
cell  was  interposed.  In  1795  repeated  minute  injections  led  him 
to  doubt  the  existence  of  this  sort  of  cell ; and  about  the  close  of 
1805  he  publicly  demonstrated  the  fact,  that  many  veins  of  consi- 
derable calibre  collected  in  the  manner  of  a plexus,  with  corre- 
sponding arteries,  hut  small  and  less  numerous,  really  form  the 
outer  and  inner  membranes  of  the  urethra,  the  whole  of  the  glans 
penis,  and  the  whole  substance  of  the  spongy  body.  In  each  of 
these  parts,  and  also  in  the  spongy  structure  inclosing  the  orifice 
of  the  vagina,  he  ascertained  by  repeated  injections  that  there  are 
no  cells,  as  was  imagined,  and  that  the  arteries,  reflected,  as  it 
were,  give  origin  to  numerous  veins,*  which,  forming  an  intimate 
plexiform  net-work,  constitute  the  whole  glans,  and  the  entire  vascu- 
lar body  which  surrounds  the  urethra  and  the  entrance  of  the  vagina. 

In  the  cavernous  bodies  of  the  penis  and  clitoris  he  had  not  suf- 
ficient facts  to  ascertain  the  existence  of  the  same  structure,  as  he 
had  never  succeeded  in  injecting  these  parts  so  completely  as  the 
glans  and  the  spongy  part  of  the  urethra.  Eventually,  however,  he 
succeeded,  especially  in  children,  in  injecting  fully  these  cavernous 
bodies  of  the  penis  and  clitoris.  He  found  in  their  interior  nothing  but 
fasciculi  of  veins,  with  corresponding  arteries,  though  rather  smaller. 
He  inferred,  therefore,  that  these  vessels,  collected  and  ramified  in 
various  directions,  constitute  a vascular  texture  capable  of  expand- 
ing and  shrinking,  according  to  the  quantity  of  blood  conveyed  to  it.f 

* “ Le  arterie  vi  si  ritorcono,  et  danno  origine  alle  vene,  e queste  formano  in  seg>iito 
alcuni  plessi,  i quali  accumulati  in  varia  maniera,  instituiscono  tutto  il  glande,  e tutta 
quella  massa  vascolare,  che  trovasi  intorno  al’  canale  deil’  uretra,  e all’  ingresso  deUa 
vagina.”  Prodromo  della  Grande  Anotomia  di  Paolo  Mascagni.  Folio,  Firenze,  1819, 
Capitolo,  II.  p.  61. 

t Prodromo  del  Paolo  Mascagni,  loco  citato,  p.  61. 


172 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


The  general  accuracy  of  this  description  has  been  since  confirmed 
by  the  researches  of  Paul  Farnese  and  Moreschi.  The  latter  espe- 
cially has  shown,  Is^,  That  the  glans  consists  of  arteries  and  a very 
great  number  of  minute  veins,  which  pour  their  blood  into  the  cu- 
taneous dorsal  vein  ; 2d,  That  the  urethra,  and  especially  its  poste- 
rior part,  may  in  like  manner  be  shown  to  consist  of  numerous 
minute  veins,  which  terminate  in  a posterior  branch  of  the  dorsal 
vein,  and  communicate  with  the  veins  of  the  bulbous  portion  of  the 
urethra ; and  3c?,  That  in  the  cavernous  bodies,  though  also  re- 
ceiving blood-vessels,  these  are  much  less  numerous,  and  are  chiefly 
derived  from  the  urethral  vessels.* 

The  same  arrangement  was  recognized  by  Cuvier  in  the  penis  of 
the  elephant,  and  by  Tiedemann  in  that  of  the  horse. 

Upon  the  whole,  the  fiicts  collected  by  different  anatomists  on 
this  subject  furnish  the  following  results. 

If  the  arteries,  on  the  one  hand,  be  injected,  they  are  found  to 
terminate  in  very  fine  ramifications,  the  disposition  of  which  is  ex- 
actly the  same  as  in  other  parts.  If,  on  the  other,  the  veins  be 
injected,  it  is  easy  to  perceive  the  two  following  circumstances. 
l5^.  That  they  are  much  dilated  at  their  origin,  that  is,  that  the 
venous  radiculoE  are  really  more  dilated  than  might  be  anticipated 
from  the  other  characters  of  these  vessels.  2d,  That  the  tubular 
dilatations  to  which  they  are  accessory,  form  very  numerous  inos- 
culations or  anastomoses,  precisely  as  the  capillary  system  of  which 
they  constitute  a part.  The  effect  of  this  arrangement  is  to  give 
these  vessels  the  appearance  of  being  penetrated  with  sieve-like 
openings,  which  makes  them  resemble  areola,  or  interlaminar  spaces 
mutually  communicating.  As  the  whole  difference,  therefore,  be- 
tween the  capillary  vessels  of  this  and  other  parts  of  the  human 
frame,  consists  in  the  minute  veins  {I’adicula  venosa^  being  dilated 
or  distended  in  a peculiar  manner,  M.  Bedard  concludes,  that  the 
erectile  tissue  of  the  cavernous  body  consists  simply  of  minute  ar- 
teries and  dilatable  veins  interwoven  in  the  manner  of  capillary 
nets.  These  distended  venous  cavities  are  indeed  so  remote  from 
being  cells,  that  they  are  truly  continuous  with  veins,  the  inner 
membrane  of  which  may  be  easily  recognised  among  thern.f 

* Commentarium  de  Urethrse  Corporis  Glandisque  Structura  6to  Tdus  Decembris 
1810  detecta  Alexandri  Moreschi,  Eq.  Coron.  Ferreee  in  Ticinensi  primum,  turn  Bo- 
noniensi  Archigymnasio,  Anatomes  Professoris.  Mediolani,  1817. 
t Additions,  p.  119. 


ERECTILE  TISSUE. 


173 


During  erection  the  blood  accumulates  in  this  tissue ; but  the 
cause  and  mechanism  of  this  accumulation  are  completely  unknown. 

Since  these  observations  were  made,  M.  Muller  of  Berlin  has, 
by  injecting  the  arteries  of  the  penis,  been  enabled  to  give  a more 
detailed  and  satisfactory  account  still  of  the  peculiar  arrangement 
of  the  erectile  vessels. 

By  injecting  the  principal  artery  of  the  penis  before  its  subdivi- 
sion, and  dividing  longitudinally  one  of  the  corpora  cavernosa^  the 
ramifications  of  the  nutrient  arteries  are  then  seen  upon  the  inner 
side  of  the  venous  spaces,  the  arteries  becoming  smaller  and  smaller, 
until  they  pass  into  the  capillary  network,  where  their  divisions  can- 
not be  seen  by  the  naked  eye.  Besides  these  nutrient  ramified 
arteries,  there  is  seen  on  careful  inspection  another  set  of  arterial 
branches  of  diflferent  size,  form,  and  disposition,  which  are  given 
oflF  nearly  at  right  angles  from  both  the  larger  and  smaller  trunks. 
These  arterial  processes  are  about  one-hundreth  of  an  inch  in  dia- 
meter, and  one-twelfth  long,  and  are  easily  seen  by  the  naked  eye. 
They  project  into  the  cavities  of  the  spongy  substance,  and  termi- 
nate either  bluntly  or  by  dilated  extremities,  without  undergoing 
any  ramification.  These  short  arterial  processes  are  turned  round 
at  their  extremities  into  a semicircle  or  more,  and  present  a spiral 
appearance  like  the  extremity  of  a screw.  This  disposition  sug- 
gested to  M.  Muller  the  name  of  Helicine,  or  spiral  or  screw-like 
arteries;  {ArtericE  Helicine.)* 

The  helicine  arteries  of  the  penis  are  more  easily  seen  in  man 
than  in  any  other  animal  which  Professor  Muller  has  examined. 
He  has  found  them  in  all  the  animals  in  which  he  has  sought  for 
them  ; they  are  to  be  seen  at  the  posterior  part  only  of  the  penis 
in  the  stallion,  but  in  the  dog  exist  throughout  the  whole  organ. 

In  man,  the  helicine  twigs  of  the  penal  arteries  sometimes  come 
oflp  singly,  and  at  other  times  they  form  tufts  or  bunches,  consisting 
of  from  three  to  ten  branches,  and  having  in  general  a very  short 
common  stem.  The  swelling  at  the  extremity,  when  it  occurs,  is 
gradual,  and  is  greatest  a little  way  from  the  end.  The  helicine 
branches  given  off  from  large  arteries  are  not  of  a greater  size  than 
those  coming  from  smaller  ones,  and  even  the  smallest  capillary 
arteries  of  the  profunda  penis^  which  can  be  seen  with  the  help  of 
a glass  only,  give  off  helicine  twigs  of  a much  greater  size  than 
themselves. 

* Ueber  die  Arteri®  Helicin®.  Von  Johann  Dr  MiiUer,  Archive  fur  Anatomie 
und  Physiologic,  Heft  II.  1835. 


174 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Each  helicine  branch  projecting  into  a venous  cavity  is  covered 
by  a thin  membrane,  which  Professor  Muller  regards  as  the  inner 
coat  of  the  dilated  vein,  and  when  there  is  a tuft  of  helicine  twigs, 
the  whole  tuft  is  covered  with  one  envelope  of  a gauze-like  mem- 
brane. This  covering  is  considerably  thicker  on  the  helicine  arte- 
ries in  the  posterior  part  of  the  corpus  spongiosum  urethrae  than  in 
the  corpus  cavernosum ; but  it  is  probable  that  this  is  in  some 
measure  connected  with  the  state  of  repletion  of  the  arteries ; for 
when  the  injection  has  run  well,  it  becomes  difficult  to  distinguish 
the  external  covering. 

Professor  Muller  could  not  discover  any  apertures  either  in  the 
sides  or  in  the  ends  of  the  helicine  arteries ; but  he  seems  to  regard 
it  as  probable  that  there  are  minute  apertures,  which  may  be  of  a 
nature  to  allow  the  passage  of  blood  in  some  states  and  not  in  others. 

The  helicine  arteries  are  not,  as  some  may  suppose,  loops  of  ves- 
sels which  have  been  incompletely  filled,  and  which,  after  making 
a coil,  pass  into  venous  spaces,  as  E.  H.  Weber  discovered  to  be  the 
case  with  the  arteries  of  the  maternal  portion  of  the  placenta. 
They  are  merely  branches  projecting  from  the  arterial  trunks  con- 
taining blood. 

The  helicine  arteries  are  more  numerous  towards  the  root  than  near 
the  point  of  the  penis.  They  are  observed  in  the  corpus  spongiosum 
urethrae,  especially  towards  its  bulb,  but  they  are  not  so  easily  seen 
there  as  in  the  corpora  cavernosa.  They  have  not  yet  been  observed 
in  the  glans.  Their  structure  is  nearly  the  same  in  all  the  animals 
in  which  they  have  been  observed  ; those  of  the  ape  bear  the  near- 
est resemblance  to  those  of  man,  and  in  most  animals  they  are  less 
obvious  than  in  the  human  subject.  In  the  horse  and  dog  they 
give  off  small  nutrient  twigs  from  their  sides,  which  render  them 
more  difficult  to  be  seen  in  these  animals  than  in  man. 

It  seems  not  doubtful  that  the  accumulation  of  blood  in  these 
helicine  arteries  is  the  physiological  cause  of  the  phenomena  of 
erection. 

The  spleen,  M.  Bedard  thinks,  may  be  said  to  resemble  the  ca- 
vernous body  both  in  structure  and  phenomena ; and  he  considers 
it  as  at  once  consisting  of  erectile  tissue,  and  to  be  the  seat  of  a 
species  of  erection  more  or  less  similar  to  that  of  the  cavernous 
body.  This  organ,  he  argues,  becomes  the  occasional  seat  of  a 
motion  of  expansion  and  contraction ; and  he  adduces  the  three 
following  conditions  in  which  it  takes  place.  \st,  In  experiments  ; 
when  in  a living  animal  the  course  of  the  blood  in  the  splenic  veins 


ERECTILE  TISSUE. 


175 


is  arrested,  the  spleen  swells,  but  returns  to  its  former  dimensions 
as  soon  as  the  circulation  is  restored,  2<7,  In  diseases ; the  parox- 
ysms of  intermittent  fever  are  accompanied  with  obvious  enlarge- 
ment of  this  organ,  which  subsides  at  the  conclusion  of  the  parox- 
ysm. It  appears  that  the  same  phenomenon  takes  place  during 
digestion. 

Sir  Everard  Home,  with  the  assistance  of  the  microscopic  in- 
spection of  M.  Bauer,  has  made  many  observations  on  the  struc- 
ture of  this  organ.  But  his  purpose  appears  to  have  been  more 
particularly  directed  to  ascertain  the  phenomena  of  its  function  and 
uses ; and  1 cannot  discover  that  his  ideas  on  its  intimate  struc- 
ture, and  the  arrangement  of  its  capillary  system,  are  very  precise 
or  distinct. 

The  most  distinct  examples,  in  short,  of  erectile  tissue  are  to  be 
found,  according  to  Bedard,  in  the  spongy  texture  which  surrounds 
the  urethra^  in  the  cavernous  body  of  the  clitoris,  the  vascular 
structure  of  the  nymphos,  and  in  the  nipple  of  the  female.  The 
structure  of  the  lips  in  both  sexes  is  not  unlike.  The  veins  of 
these  parts  may  be  shown  to  be  well-marked  and  largely  dilated 
at  their  origin,  so  as  to  give  the  appearance  of  cellular  net-work. 
The  same  disposition  is  observed  in  the  pulp  of  the  fingers.  It  has 
been  attempted  to  explain  the  motions  of  the  iris  by  supposing  it 
to  be  formed  of  this  erectile  tissue ; but  the  justice  of  this  conjec- 
ture seems  doubtful. 

In  the  tissue  now  described  it  is  manifest  that  the  physiologist 
ought  to  place  the  phenomena  of  the  process  distinguished  by  the 
name  of  vital  turgescence  {turgor  vitalis)  by  Hebenstreit,* * * §  Reil,f 
Ackermann,!  and  Schlosser.§  Though  these  authors  suppose  vital 
turgescence  in  different  degrees  in  almost  all  the  textures  of  the 
animal  body,  their  most  distinct  examples  are  taken  from  those 
parts  which  consist  of  erectile  vessels.  After  the  explanation  of 
the  anatomical  structure  above  given,  it  is  superfluous  to  seek  for 
any  other  cause  except  the  arrangement  of  the  minute  vessels,  their 
helicine  termination,  and  the  disposition  of  the  veins. 

* Brevis  Expositio  Doctrinse  Physiologicae  de  Turgore  Vitali.  1795.  Ab  Ernesto 
Benjamino  Gottlieb  Hebenstreit,  M.  D.,  &c.,  extat  in  Brera  Sylloge  Opusculorum  Se- 
lect. Vol.  II.  Opusc.  vi. 

f Archiv.  fiir  die  Physiologic,  I.  Band,  2.  Heft,  S.  172. 

$ Ackermann  Physische  Darstellung  der  Lebenscraft,  1797.  1.  Band,  S.  11. 

§ Georgii  Eduardi  Schlosser  Dissertatio  de  Turgore  Vitali  ext.  in  Brera  Sylloge,  Vol. 
VII.  Opusc.  ii. 


176 


GENERAL  AND  PATHOLOGICAL  AJ^JATOMY. 


Section  IL 

Little  is  known  regarding  the  peculiar  pathological  states  of  this 
tissue. 

1.  Rupture  of  its  vessels  occasionally  occurs,  but  is  not  attended 
with  peculiar  phenomena,  unless  there  is  an  external  communica- 
tion, when  hemorrhage  takes  place. 

2.  It  is  liable  to  a peculiar  species  of  enlargement  or  swelling, 
in  which  the  parts  are  very  tense,  and  resemble  a swollen  bladder. 
They  have  an  oedematous  appearance,  yet  it  is  not  oedema.  This 
is  often  seen  in  phimosis  and  paraphimosis,  in  enlargement  of  the 
mjmplKB  and  lahia  in  females,  and  in  a swelling  incident  to  the 
eyelids  after  the  application  of  leeches  in  both  sexes. 

This  swelling,  I think,  is  most  usually  connected  with  some  mor- 
bid state  of  the  surface  of  the  parts ; either  inflammation,  as  in  go- 
norrhoea and  leucorrhoea,  or  an  abrasion,  an  ulcer,  or  laceration,  or 
some  similar  lesion. 

3.  Priapism  is  a morbid  state  of  the  erectile  tissue  of  the  caver- 
nous body.  The  painful  and  anomalous  mode  of  erection  termed 
chordee  appears  to  depend  on  the  erectile  tissue  of  the  corpus  spon- 
giosum being  unduly  irritated  by  the  presence  of  the  inflamma- 
tory stimulus  in  the  urethral  membrane  and  its  submucous  tissue. 
There  is  at  the  same  time,  however,  a spasm  of  the  erector  muscle, 
(ischio-cavernosus,)  which,  Haller  justly  remarks,  instead  of  erect- 
ing the  penis,  ought  to  depress  it. 

4.  Is  the  erectile  tissue  more  prone  to  hemorrhage  than  others  ? 
Is  this  hemorrhage  more  frequently  venous  than  arterial  ? These 
are  points  on  which  we  have  almost  no  certain  information.  Urethral 
hemorrhage,  when  violent  and  copious,  may  depend  on  rupture  of 
the  erectile  tissue  of  the  spongy  body,  or  those  vessels  of  the  ure- 
thra which  have  been  well  delineated  by  Mr  Shaw.*  When  it  is 
so  copious  as  to  be  restrained  with  difficulty,  there  is  reason  to  be- 
lieve that  a communication  is  opened  between  the  urethra  and  the 
communicating  veins  of  the  spongy  body. 

It  may  here  be  mentioned  that  hemorrhage  from  the  vagina, 
whether  intentionally  or  accidentally  inflicted,  is  always  most  pro- 
fuse and  copious,  and  difficult  to  be  restrained.  From  this  cause 
various  females  in  this  country  have  died,  before  adequate  means 

* Medico-Chirurgical  Transactions,  Vol.  X.  p.  342  and  357. 


ERECTILE  TISSUE. 


177 


to  suppress  the  hemorrhage  could  be  adopted.  This  is  manifestly 
dependent  on  the  plexiform  arrangement  of  the  multiplied  venous 
vessels  by  which  the  vaginal  mucous  membrane  is  surrounded. 

5.  The  disease  described  by  John  Bell  and  Mr  Freer*  under  the 
name  of  aneurism  by  anastomosis^  {aneurysma  per  anastomosin')^ 
termed  by  Meckel  angiectasia,  (Ayysiov  ixraaig,  vasorum  dilataiio,) 
and  by  some  of  the  German  pathologists,  telangiectasis,  (vasorum 
ultimorum  distensio,)  appears  to  be  an  accessory  or  morbid  form  of 
erectile  tissue  occurring  in  parts  naturally  provided  with  simple 
capillary  tissue.  In  some  circumstances  it  is  a congenital  disease, 
and  appears  at  birth  like  a ncevus  maternus.  In  its  early  stage  the 
tumour  is  a mere  pimple,  and  appears  to  consist  of  a congeries  of 
arteries  and  veins.|  In  this  state  it  is  firm,  and  the  throbbing  is 
indistinct ; but  as  the  cellular  net-work,  which  ultimately  forms  the 
bulk  of  the  swelling,  is  developed,  it  becomes  more  compressible, 
and  the  pulsation  becomes  more  evident.  At  last  it  appears  to 
consist  of  a cluster  of  sacs  of  a purple  or  livid  colour,  which  burst 
from  time  to  time,  and  bleed  profusely.  Anastomotic  aneurism 
may  occur  in  any  part  of  the  body  in  which  the  capillary  vessels 
are  numerous.  Mr  Bell  saw  it  in  the  face,  near  the  angle  of  the 
eye.  Mr  Freer  saw  it  within  the  mouth,  between  the  gums  and 
the  cheek.  I have  seen  it  on  the  skin  of  the  nose  and  on  the  gum. 

In  two  instances  in  which  I saw  it  on  the  skin  of  the  nose,  the 
body  resembled  a small  reddish  mark  on  the  skin,  about  the  size 

* Observations  on  Aneurism  and  some  Diseases  of  the  Arterial  System.  By  George 
Freer,  Fellow  of  the  Royal  College  of  Surgeons,  London,  &c.  Birmingham,  1807,  p. 
34. 

t The  Principles  of  Surgery,  in  Two  Volumes,  &c.  by  John  Bell,  Surgeon,  Discourse 
XT.  p.  4S6,  Vol.  I.  4to  Edition.  1801. 

J “ The  tumour  is  a congeries  of  active  vessels  ; and  the  cellular  substance  through 
which  these  vessels  are  expanded  resembles  the  cellular  part  of  the  penis,  the  gills  of 
a turkey  cock,  or  the  substances  of  the  placenta,  spleen,  or  womb.  It  is  apparently  a 
very  simple  structure  that  enables  those  parts,  (the  womb,  the  penis,  the  spleen,)  to 
perform  their  functions  ; and  it  is  a very  slight  change  of  organization  that  forms  this 
disease.  The  tumour  is  a congeries  of  small  and  active  arteries,  absorbing  veins,  and 
intermediate  cells.  The  irritated  and  incessant  action  of  the  arteries  fills  the  cells  with 
blood  ; from  these  cells  it  is  reabsorbed  by  the  veins  ; the  extremities  of  the  veins 
themselves  perhaps  dilate  into  this  cellular  form.  There  seems  to  be  a perpetual 
circulation  of  blood  ; for  there  is  incessant  pulsation.  The  tumour  is  permanent,  but 
its  occasional  variation  of  bulk  is  singular.  It  swells  like  the  penis  in  erection,  or  the 
gills  of  a turkey-cock  in  a passion.  It  is  puffed  up  by  exercise,  di-inking,  or  emotions 
of  the  mind.  It  is  filled  and  distended  with  blood  upon  any  occasion  which  quickens 
the  circulation,  as  by  venery,  menstruation,  the  pleasures  of  the  table,  heated  rooms, 
or  the  warmth  of  the  bed.” — Principles  of  Surgery,  p.  457. 

M 


178 


GENERAL  AND  PATHOLOGICAL  ANATOBIY. 


of  a split  pea,  without  elevation,  but  presenting,  when  closely  ex- 
amined, a cluster  of  minute  vessels  proceeding  from  a circumfe- 
rence to  a point,  in  the  asteroid  form.  In  both  cases  they  were 
liable  to  become  red  and  uneasy  on  exposure  to  external  heat, 
during  blushing,  and  on  any  excited  state  of  the  circulation.  When 
pressed,  the  vessels  seemed  to  be  for  one  moment  emptied  and  then 
to  be  immediately  filled,  giving  the  part  a deeper  red  colour  than 
before.  In  the  instance,  in  which  I saw  the  tumour  on  the  gum, 
{parulis  aneurysmatica,')  the  form  of  the  disease  was  greatly  more 
distinct.  It  appeared  in  the  form  of  a tumour  of  the  size  of  a 
large  pea,  situated  in  the  gum  of  the  upper  jaw.  It  pulsated 
strongly  and  distinctly,  and  was  the  seat  of  a disagreeable  sensa- 
tion of  heat  and  throbbing.  When  situate  on  the  mucous  surfaces, 
these  tumours  are  liable  to  attacks  of  hemorrhage ; and  occasion- 
ally this  accident  takes  place  in  those  of  the  skin. 

When  it  occurs  on  the  surface  of  the  body,  its  covering  is  so 
thin  as  to  appear  destitute  of  the  usual  corion.  The  pulsation  in 
the  tumour  is  increased  by  all  those  causes  which  accelerate  the 
action  of  the  heart.* 

The  arterial  disease  found  often  affecting  the  branches  of  the 
temporal,  posterior  aural,  and  occipital  arteries,  as  described  by 
Mr  Maclure,  Mr  Maclachlan,  Mr  Syme,  and  M.  Lallemand,  is 
manifestly  the  same  affection  as  that  already  noticed  under  the 
head  of  arterial  varix  and  cirsoid  aneurism.  The  arteries  are 
dilated,  tortuous,  and  serpentine  ; the  tunics  of  the  vessels  are  thin, 
flaccid  and  feeble,  and  pulsate  strongly ; while  occasionally  after 
death  these  vessels  are  observed,  like  veins,  to  have  undergone  the 
suppurative  inflammation.! 

6,  Osteo-aneurism.  Not  dissimilar  to  the  anastomotic  aneui’ism 
is  a species  of  throbbing  tumour  observed  by  Pearson,!  and  fully 
described  by  Scarpa.§  In  the  latter  instance  a pulsating  tumour, 
which  had  gradually  attained  the  size  of  the  fist,  was  formed  in  the 
substance  of  the  anterior  part  of  the  tibia,  beneath  the  periosteum, 
which  had  become  thick  and  fleshy,  and  formed  a sort  of  contain- 
ing membrane.  Its  inner  surface  was  villous  and  irregularly 

* For  further  details  on  this  subject  the  reader  may  consult  Warren  on  Tumours, 
section  viii.  Boston,  1837. 

t Breschet,  Memoires  de  I’Academie,  Tome  III.  p.  161. 

J Medical  Communications,  Vol.  II.  p.  95  and  100. 

§ A Treatise  on  the  Anatomy,  Pathology,  and  Surgical  Treatment  of  Aneurism. 
By  Antonio  Scarpa.  Edinburgh,  1808,  Case  x.  p.  439. 


ERECTILE  TISSUE. 


179 


spongy,  like  the  utei’ine  surface  of  the  placenta ; and  wax  injected 
into  the  popliteal  artery  escaped  from  it,  and  was  deposited  be- 
tween layers  of  coagulated  blood,  which  must  have  proceeded  from 
vessels  opening  on  this  surface.  The  substance  of  the  tibia  at  the 
bottom  of  the  cavity  was  rough,  corroded,  and  partly  destroyed. 

After  the  limb  was  removed  the  patient  remained  well  for  five 
years,  when  the  stump,  and  eventually  the  whole  thigh,  was  attack- 
ed with  painful  pulsation.  At  death,  which  soon  took  place,  the 
substance  of  the  thigh-bone  was  found  to  be  removed  by  absorption 
from  the  cut  end  to  near  the  neck  ; and  the  periosteum,  which  was 
much  thickened,  was  interspersed  with  largely  dilated  vessels,  and 
formed  a sort  of  capsule  or  inclosing  membrane  to  the  diseased  parts. 

This  disease  differs  from  anastomotic  aneurism  in  its  pulsation 
and  distension  being  at  all  times  the  same,  and  in  not  presenting 
the  phenomena  of  erection.  Though  it  is  mentioned  in  this  place 
from  its  general  resemblance  to  that  disease,  it  may  be  more  justly 
regarded  as  genuine  aneurism  of  the  capillaries,  or  rather  aneurism 
of  the  arteries  of  bone. 

Morbid  States  of  the  Spleen  as  an  erectile  organ. 

1.  Softening.  The  most  common  morbid  state  of  the  splenic  tissue 
is  that  of  softening.  This  may  be  various  in  degree.  In  the  least 
severe  the  texture  of  the  spleen  is  lacerable ; and  when  torn,  the 
surfaces  present  a good  deal  of  the  natural  structure  of  the  organ 
in  the  form  of  fibres  and  vessels,  and  filaments  of  some  firmness. 
In  the  next  stage,  the  softening  is  more  complete  and  the  organ 
may  be  crushed  between  the  fingers.  "When  a stream  of  water  is 
directed  on  the  surface,  it  washes  away  much  wine-red-colour- 
ed fluid,  leaving  shreds  and  filaments.  In  the  third  and  most  com- 
plete degree  of  this  lesion,  the  spleen  is  converted  into  a soft  semi- 
fluid pulpy  mass,  of  a dark-red  or  deep  pink  colour,  like  thick  wine- 
lees,  with  nothing  but  a few  shreds  and  filaments  left. 

This  change  of  consistence  takes  place  in  ague,  remittent  fever, 
yellow  fever,  typhus,  occasionally  in  puerperal  fever,  and  sometimes 
in  diseases  of  the  stomach  and  alimentary  canal. 

The  nature  and  origin  of  softening  of  the  spleen  is  not  perfect- 
ly known.  If  not  an  effect  of  inflammation,  it  must  he  regarded 
as  one  of  excessive  vascular  distension.  It  is  associated  with  that 
state  in  which  the  internal  vascular  system  in  general,  and  that  of 
the  abdomen  in  particular,  is  for  a long  time  inordinately  distended. 
Inflammation,  it  must  be  remembered,  has  the  effect  of  destroying 


180 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  cohesion  of  tissues,  and  thereby  causing  softening.  It  seems  to 
be  in  fever  a mortal  lesion. 

2.  Splenia ; Splenitis ; Lienia.  The  spleen  appears  to  be  liable  to 
four  forms  of  inflammatory  action;  proper  inflammation,  ter- 
minating in  resolution  or  suppuration ; 2d,  suppurative  inflamma- 
tion ; 3r/,  simple  enlargement  from  vascular  distension ; and,  Ath, 
enlargement,  with  induration  of  its  tissue. 

Simple  inflammation,  though  not  common,  does  take  place.  In 
two  cases  of  inflamed  spleen  examined  by  Dr  William  blunter, 
where  the  inflammation  had  advanced  to  suppuration,  the  patients 
could  not  define  accurately  the  seat  of  the  pain,  which  seemed  to 
travel  over  the  general  cavity  of  the  abdomen.  In  another  case, 
in  which  Anthony  de  Haen  found  the  spleen  distended  with  a large 
quantity  of  thick  white  purulent  matter,  the  symptoms  had,  during 
the  inflammatory  stage,  been  ascribed  to  pleurisy. 

Both  Schmidt,  Heusinger,  and  Grottanelli  record,  in  like  man- 
ner, instances  in  which  suppuration  had  taken  place  in  the  spleen 
without  the  production  of  any  manifest  symptom  or  local  uneasi- 
ness, sufficient  to  lead  the  circumstance  to  be  suspected,  except  ge- 
neral bad  health  and  wasting.  A remarkable  case  of  this  kind  is 
recorded  by  Dr  Abercrombie,  in  which  the  patient,  after  slight  ca- 
tarrhal symptoms,  pined  away  without  distinct  local  uneasiness  for 
six  months,  and  died  wasted  and  weakened,  latterly  with  diarrhoea 
of  two  days’  standing ; and  upon  inspection  the  spleen  contained  se- 
veral ounces  of  purulent  matter.  Similar  instances  of  purulent 
collections  in  the  spleen,  where  no  indication  of  previous  disorder 
was  afforded,  have  come  under  my  notice  in  the  course  of  inspect- 
ing bodies  at  the  Royal  Infirmary. 

These  facts  show  clearly  that  suppuration  of  the  spleen  may  take 
place  without  being  attended  with  evident  or  urgent  external  symp- 
toms. In  this  case  it  may  become  a question  whether  the  suppu- 
ration is  the  effect  of  acute  inflammation,  or  rather  of  a peculiar 
chronic  suppurative  action, — connected  probably  with  that  conve- 
nient and  ill-defined  abstraction,  the  strumous  diathesis.  It  must 
not  be  imagined,  nevertheless,  that  no  symptoms  are  produced  by 
this  disorder.  There  are  always  wasting  or  pining,  considerable 
weakness,  sometimes  a thin  unhealthy  look,  sometimes  slight  dys- 
peptic symptoms,  and  sometimes,  though  more  rarely,  a sense  of 
uneasy  fulness  deep  in  the  left  hypochondriac  region.  The  most 
perplexing  part  of  the  semiography  and  symptomatology  is  this,  that 


EEECTILE  TISSUE. 


181 


these  purulent  collections  cause  almost  no  uneasy  feelings,  till  by 
their  size  they  induce  distension  or  painful  stretching  of  the  organ, 
or  pressure  or  tension  of  some  of  the  surrounding  parts. 

In  such  circumstances,  it  is  chiefly  by  negative  signs  that  the 
practitioner  can  infer  the  existence  of  disease,  in  the  shape  of  in- 
flammation or  abscess  of  the  spleen ; and,  if  he  meets  with  a case 
in  which  the  patient  pines  away,  without  cough,  expectoration,  ca- 
vernous respiration  in  the  chest,  or  the  signs  of  empyema  in  the 
side,  or  indications  of  enlarged  liver,  or  ulceration  of  the  intestinal 
mucous  membrane,  he  may  then  infer  the  probable  existence  of 
suppurative  or  other  disorder  of  the  spleen. 

This  disease  is  rare,  and  therefore  not  well  known  ; but  the  prac- 
titioner must  not  expect,  like  Pemberton,  never  to  meet  with  it. 
Abscess  of  the  spleen  is  sometimes  found  to  be  the  only  morbid 
appearance  in  sundry  cases  of  long  ill  health,  with  waiting  and 
hectic  fever. 

3.  It  is  not  perfectly  ascertained  whether  the  form  of  simple 
enlargement  of  the  spleen,  or  the  enlargement  with  induration 
ever  proceeds  to  suppuration,  or  whether  suppuration  and  abscess 
of  the  spleen  is  in  certain  circumstances  the  result  of  one  peculiar 
form  of  inflammation.  P rom  the  testimony  of  Grottanelli  suppu- 
ration of  the  spleen  seems  a lesion  not  unfrequent  in  Tuscany  and 
other  aguish  districts  in  Italy.  * M.  Raikem  of  Vol terra  records  in 
a young  book-keeper  of  21,  a case  of  splenitis  ending  in  an  exten- 
sive collection  of  fetid  purulent  matter,  in  which,  from  the  pro- 
gress of  the  symptoms,  there  is  reason  to  believe  that  the  organ  had 
been  affected  at  first  with  simple  enlargement  from  vascular  dis- 
tension. The  whole  duration  of  the  disease  appears  to  have  been 
rather  more  than  three  months ; the  acute  symptoms  for  which  the 
patient  was  under  the  care  of  M.  Raikem,  two  months ; and  the 
tumour  of  the  left  hypochondre,  which  was  at  first  hard  and  re- 
sisting, and  extended  to  the  linea  alba  and  navel,  became  about 
the  sixth  week  soft,  increasing  in  size,  and  afterwards  diminishing 
remarkably. 

Inspection  of  the  body  disclosed  the  following  facts.  The  left 
pleura  contained  more  than  two  pounds  of  citron-yellow  serous 
fluid,  with  albuminous  flakes  floating  in  it.  The  pleura  of  that  side 
was  covered  by  a thin  coating  of  concrete  puriform  matter,  and  was 

* Ad  Acutae  et  Chronicae  Splenitidis  in  huniilibus  praesertim  Italiae  locis  conside- 
ratae  eidemque  succedentinm  Morbomm  Historias  Animadversiones.  Auctore  Stanis. 
lao  Grottanelli,  Philosoph,  Med.  et  Chir.  Doctore.  Florentiae,  1821.  8vo. 


182 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


reddish,  and  had  the  appearance  of  being  slightly  thickened.  The 
corresponding  lung  was  crepitant  and  void  of  tubercles.  Its  pleura 
adhered  to  the  costal  pleura  by  means  of  soft  recent  albuminous 
bridles ; and  the  lobes  were  connected  in  the  same  manner. 

The  upper  portion  of  the  descending  colon  and  the  large  end  of 
the  stomach  adhered  closely  to  the  spleen.  This  organ  was  twice 
its  ordinary  size,  and  was  of  a crimson  red  colour  at  the  margins. 
The  portion  of  the  abdominal  peritoneum,  corresponding  to  the 
posterior  splenic  surface,  was  raised  by  a white,  thick,  purulent, 
very  fetid  liquid,  proceeding  from  the  interior  substance  of  the 
spleen,  which  was  hollowed  into  a large  abscess  with  purulent-lined 
walls.  The  contents  had  been  effused  between  this  serous  mem- 
brane and  the  adjoining  muscular  layer,  the  vertebral  column,  and 
left  kidney,  and  had  extended  to  the  crural  arch.  * 

It  seems  probable  that  this  is  an  example  of  suppurative  inflam- 
mation from  the  commencement. 

In  some  instances  of  suppuration  or  abscess  of  the  spleen,  instead 
of  one  large  abscess,  several  small  ones  are  observed.  These  are 
probably  of  a more  chronic  character,  and  perhaps  are  indications 
of  the  strumous  diathesis.  A case,  in  which,  in  a young  woman  of 
20,  the  spleen  contained  two  circumscribed  abscesses,  is  given  by 
Dr  Tweedie  in  his  Illustrations  of  Fever.  In  this  case  there  were 
ulcers  in  the  intestinal  mucous  membrane. 

Do  these  collections  ever  find  their  way  to  the  surface  by  means 
of  progressive  absorption  ? Fantoni  gives  an  instance  of  one  which 
had  opened  at  the  navel  in  a female,  and  who  recovered  her  health 
and  afterwards  bore  a child.  Five  years  afterwards  she  died,  and 
upon  inspecting  the  body  after  death  no  trace  of  spleen  was  found. 

The  following  case  is  given  by  Grottanelli.  A Franciscan 
monk,  aged  sixty-seven,  a sufferer  from  ague,  was  attacked,  in  the 
autumn  of  1812,  with  pain  in  the  region  of  the  spleen,  where  was 
a hard  painful  swelling.  At  the  end  of  eighteen  days  the  pain  was 
abated ; but  there  appeared  in  the  abdomen,  near  the  Iznea  alba^  a 
considerable  convex  swelling  with  fluctuation.  Three  days  after, 
under  the  use  of  anodyne  plasters,  an  opening  spontaneously  took 
place  ; and  there  was  discharged  a fluid  partaking  of  the  character 
of  steatomatous  and  albuminous  matter.  Of  this  forty-eight  ounces 
were  discharged  the  first  day,  and  as  much  on  each  of  the  three  fol- 
lowing days.  At  the  end  of  thirty  days  the  patient  was  well ; the 
spleen  v'as  a little  lai’ger  than  natural,  but  without  pain  and  un- 

* Breschet,  Repertoire  General  cl’Anatomie  et  de  Physiologie,  Tome  vii.  p.  115. 

4 


ERECTILE  TISSUE. 


183 


easiness.  This  person  lived  about  two  years  afterwards.  He  was 
again  attacked  with  ague,  oedema  of  the  feet,  and  died.* 

The  external  opening  is  doubtless  the  most  favourable.  That 
into  the  stomach  or  colon,  when  it  is  followed  by  purulent  vomiting 
or  diarrhoea,  is  next  favourable.  That  through  the  diaphragm  into 
the  pleura  or  lungs  is  much  less  favourable,  and  must  he  considered 
as  peculiarly  dangerous.  And  when  the  outlet  is  made  within  the 
peritoneum,  or  without  that  membrane,  it  is  necessarily  and  very 
speedily  fatal. 

It  is  necessary  to  mention,  nevertheless,  that  Grottanelli  gives 
two  cases,  (IX.  § 53,  § 56,)  in  which  he  states  that,  notwithstand- 
ing this  kind  of  outlet  witliin  the  peritoneum,  recovery  took  place. 
In  the  first,  in  consequence  of  a kick  on  the  abdomen,  an  abscess 
of  the  spleen  had  burst  into  its  cavity  ; and  though  the  immediate 
effects  bore  all  the  characters  of  speedily  approaching  death,  yet, 
after  twenty  hours,  the  patient  began  to  rally,  and  after  voiding 
a large  quantity  of  urine-like  faeces  for  the  space  of  three  weeks, 
finally  recovered,  and  was  seen  perfectly  well  seven  years  after. 
In  the  second,  the  person  received  a kick  from  a horse  in  the  re- 
gion of  the  organ  ; yet,  after  diarrhoea  and  bloody  hypostatic  urine 
lasting  for  many  days,  he  eventually  recovered. 

4.  Simple  or  indolent  enlargement  from  vascidar  distension.  — 
Almost  all  authors  have  noticed  enlargement  of  the  spleen,  super- 
vening either  spontaneously  or  after  ague  and  other  bad  fevers. 
Morgagni  relates  an  instance  in  which  the  spleen  of  a slender  wo- 
man of  twenty-eight,  who  had  undergone  chronic  fever,  occupied 
the  whole  of  the  left  side  of  the  belly,  and  weighed  eight  pounds 
and  a-half,  without  change  of  its  interior  structure,  but  apparent 
dilatation  of  the  vessels  and  development  of  its  lymphatics ; and 
Pemberton  mentions  one  weighing  three  pounds  two  ounces,  yet 
with  perfectly  natural  structure.  Mr  Elliot  describes  one  weighing 
eleven  pounds  thirteen  ounces,  with  natm’al  structure,!  and  Bree 
states  it  to  vary  from  one  to  twenty  or  thirty  pounds  after  ague 
and  chronic  diseases  of  the  viscera.  The  natural  weight  of  the 
spleen  is  from  nine  to  fourteen  ounces.  Baillie  remarks,  that  this 
simple  enlargement  with  structure  perfectly  healthy,  happens  to  the 
spleen  more  commonly  than  to  any  other  organ,  and  regards  it 
rather  as  a monstrous  growth  than  as  actual  disease.  It  appears  to 
me  that  this  is  correct  only  to  a certain  extent ; and  that  simple 

* Ad  Acutse  et  Chronic®  Splenitidis,  &c.  Art.  V.  Hist.  XI.,  quoted  by  Raikcm, 
but  carelessly. 

•f  Med.  Com.  Vol.  XVII.  p.  497.  Stoll,  Ratio  Med.  i.  163,  251. 


184 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


enlargement  is  an  incipient  morbid  state,  which  will  progressively 
terminate  in  another  morbid  state,  which  is  distinguished  hy  less 
equivocal  organic  characters.  Pemberton  formed  a just  notion  of 
this  enlargement  or  swelling  of  the  splenic  substance,  when  he  said 
it  might  perhaps  arise  from  a larger  quantity  of  blood  being  con- 
veyed to  it  by  the  arteries,  without,  however,  these  arteries  taking 
on  that  action,  which  is  the  essence  of  inflammation.  In  short, 
whatever  be  the  remote  cause  or  the  material  agent,  the  disease 
consists  in  unusual  accumulation  of  blood  in  the  organ,  whether 
conveyed  by  arteries  or  not  removed  by  veins  ; and  if  this  accumu- 
lation continues  long,  it  .will,  under  certain  circumstances,  render 
the  organ  unusually  soft.  When  the  capsule,  which  in  such  cir- 
cumstances is  very  tender,  is  broken,  the  substance  of  the  spleen 
seems  to  consist  of  little  else  than  a very  soft  brownish  red  mucus, 
intermixed  with  a spongy  fibrous  texture.  This  softening,  as  it 
may  be  named,  appears  to  be  caused  by  the  immense  quantity  of 
blood  in  the  vessels,  producing  a slow  but  severe  disorganization  or 
breaking  down  of  the  proper  splenic  tissue.  (See  Dr  Bree’s  paper.) 
Baillie  thinks  it  is  hardly  to  be  considered  as  a disease ; but  this 
opinion,  I fear,  rests  on  no  good  foundation.  In  some  circumstan- 
ces, to  be  afterwards  specified,  the  structure  of  the  spleen  not  en- 
larged is  unusually  soft,  apparently  from  some  cadaverous  change ; 
but  the  true  softening  of  the  enlarged  organ  is  efiected  in  the  man- 
ner represented,* 

The  symptoms  of  simply  enlarged  spleen  are  not  well  known. 
The  patient  usually  complains  of  a sense  of  fulness  rather  than  pain 
in  the  left  side ; in  some  instances  pain  is  felt  when  the  left  side  is 
examined  or  pressed ; in  others  the  pain  is  not  perceived  in  the  seat 
of  the  spleen,  but  at  the  lower  part  of  the  left  side,  inclining  to- 
. wards  the  back  ;f  and  in  others,  the  swelling  may  proceed  to  a 
very  large  size  without  causing  any  uneasiness  whatever.  In  most 
cases  the  left  hypochondi'iac  region  bulges  out,  and  in  some  the 
enlargement  may  be  distinctly  felt  by  the  hand.  The  patient  can 
only  lie  on  the  left  side ; the  countenance  is  sallow,  but  not  jaun- 
diced ; hemorrhages  from  the  nose  take  place ; and  if  it  continues 
long,  it  may  cause  watery  effusion  within  the  peritoneum  ; {ascites.) 

Indolent  enlargement  of  the  spleen  may  terminate  in  resolution, 
by  subsiding  spontaneously  or  under  medical  treatment,  in  soften- 
ing with  emaciation  or  death,  or  in  induration  and  incurable  dropsy 
of  the  belly. 

* See  note  on  Cooke’s  Morgagni,  Vol.  II.  p.  176.  The  spleen,  a mass  of  gore. 

f Morgagni,  l.w.  10. 


ERECTILE  TISSUE. 


185 


The  causes  of  indolent  enlargement  are  little  known.  A long 
residence  in  districts  infested  by  intermittent  fevers,  especially  quar- 
tans, and  repeated  attacks,  or  the  prolonged  continuance  of  these 
disorders,  give  the  spleen  a tendency  to  swell ; and  the  disease  is 
common  in  fenny  and  aguish  districts,  both  in  this  island  and  on 
the  continent.  Thus  in  Lincolnshire,  Essex,  Kent,  Cambridge- 
shire, &c.  it  is  not  uncommon  ; it  assumes  its  most  formidable  ap- 
pearance in  the  department  of  the  lower  maritime  Alps  in  France ; 
in  Hungary  it  is  endemial ; and  in  the  Carolinas  and  other  south- 
ern states  of  the  American  Union,  it  is  rare  to  find  persons  who 
have  attained  thirty  or  five  and  thirty  years,  without  more  or  less 
enlargement  of  the  spleen.  In  some  instances  the  disease  succeeds 
a blow  on  the  hypochondre. 

5.  Indurated  enlargement  of  the  Spleen.  This  is  perhaps  more 
common  than  enlargement  with  softening ; for  every  enlarged 
spleen  may  in  process  of  time  become  hardened.  In  this  state  the 
organ  may  be  five  or  six  times  its  natural  size,  yet,  when  divided, 
presenting  its  natural  structure,  only  much  more  dense  and  com- 
pact than  natural.  This  is  sometimes  considered  as  scirrhus,  but 
it  is  unlike  to  this  in  other  parts  of  the  body,  and  its  real  nature  is 
not  well  understood.  It  is  not  improbable  that  it  is  the  effect  of 
chronic  inflammation.  It  is  generally  attended  with  dropsical  effu- 
sion within  the  peritoneum.  It  can  seldom  be  recognised  till  the 
disease  has  made  such  progress  that  the  enlarged  organ  is  felt  ex- 
ternally, when  it  protrudes  the  false  ribs,  and  the  anterior  edge  or 
top  of  the  organ  can  be  felt  by  the  hand  appbed  to  the  belly  under 
the  margin  of  the  ribs.  It  is  sometimes  notched.  Even  in  this 
state  the  only  symptoms  are  an  unhealthy  sallow  look,  wasting  of 
the  fleshy  parts,  and  swelling  of  the  belly,  dry  skin,  and  at  length 
the  usual  signs  of  dropsy  of  the  belly. 

The  disease  is  a common  effect  of  residence  in  aguish  districts. 
According  to  Grottanelli  it  is  endemial  in  the  territory  of  Pitigliano 
and  other  low  districts  in  Italy. 

The  size  and  weight  of  the  spleen,  when  affected  with  hypertro- 
phy and  induration,  are  seldom  so  considerable  as  when  the  disease 
is  simple  induration.  The  spleen  weighs,  then,  in  this  country, 
from  three  to  seven  pounds.  In  one  remarkable  case  which  I have 
published  for  other  reasons,  the  indurated  spleen  weighed  seven 
pounds  three  ounces  and  a-half ; and  in  another  case  which  had 
also  been  under  my  care,  and  in  which  death  took  place  in  the 
same  manner,  the  spleen  weighed  seven  pounds  twelve  ounces. 


186 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Hypertrophy  of  the  spleen  with  induration  presents  occasionally 
a singular  mode  of  termination.  When  the  swelling  has  attained 
a great  size,  the  patient  is  attacked  rather  suddenly  with  symptoms 
of  inflammatory  fever  of  considerable  intensity,  accompanied  with 
marked  disorder  in  the  circulation  of  the  brain.  The  skin  is  hot,  the 
pulse  quick,  from  100  to  110;  the  face  is  of  a deep-red  or  brown 
colour ; the  eyes  are  suflPused  and  injected ; and  the  patient  com- 
plains of  thirst  and  pain  in  some  part  of  the  head.  The  breathing 
is  also  a little  hurried  and  oppressed.  The  symptoms,  in  short, 
are  very  similar  to  those  of  phlebitis.  After  this  has  proceeded  for 
one  or  two  days,  delirium  comes  on,  the  breathing  is  more  oppressed, 
and  the  patient  expires. 

Upon  inspection  all  the  large  veins  of  the  chest  and  abdomen, 
and  the  sinuses  and  veins  of  the  brain  are  found  filled  with  masses 
of  clotted  blood  mixed  with  lymph  and  purulent  matter.  The  tu- 
nics of  the  veins,  however,  are  not  thickened,  nor  are  the  lining 
membranes  roughened. 

This  result  I have  seen  take  place  in  two  cases,  both  of  which 
were  so  carefully  observed,  that  no  error  appears  to  me  to  have 
been  committed.  The  occurrence  it  is  not  easy  to  explain.  All 
that  we  can  do  is  to  note  the  fact,  that  in  such  cases  of  splenic  dis- 
ease, a severe  lesion  is  liable  to  take  place  with  lymphy  and  pur- 
ulent deposits  in  the  venous  blood  of  the  chest,  abdomen,  and  brain.* 

6.  Tubercles  of  the  spleen  or  tyromatous  bodies  are  occasionally 
met  with.  The  organ  is  generally  enlarged  ; and  its  interior  pre- 
sents disseminated  through  it  a number  of  whitish-gray  or  cream- 
coloured  bodies,  globular  or  spheroidal,  varying  from  the  size  of 
small  peas  to  that  of  moderate  sized  beans.  Their  substance  is 
very  much  like  that  of  tyromatous  matter  in  other  parts  of  the 
body,  that  is,  a sort  of  albuminous  or  caseous  matter  without  orga- 
nization. The  splenic  tissue  is  at  the  same  time  in  general  a little 
more  consistent  than  usual. 

An  important  circumstance  to  be  observed  is  the  early  period  at 
which  tubercles  of  the  spleen  may  be  generated.  I have  seen  them 
in  infancy  before  the  termination  of  the  first  year  of  life.  This  I 
observed  in  the  body  of  an  infant  in  1832,  who  had  been  cut  off  by 
intestinal  disorder.  Tubercular  deposits  were  found  also  in  the 
lungs. 

* Case  of  Disease  of  the  Spleen,  in  which  death  took  place  in  consequence  of  the 
presence  of  purulent  matter  in  the  blood.  By  David  Craigie,  M.  D.,  &c.,  Edin.  Med. 
and  Surgical  Joiunal,  Vol.  LXIV.  p.  400. 


SYSTEM  OF  EXHAEANTS. 


187 


CHAPTER  IX. 

SYSTEM  OF  EXHALANTSy  ( Vasa  exhalantia.) — exhalant  system, — 
(^Si/steme  exhalant.) 

Section  I, 

Are  there  such  vessels  as  the  exhalants  described  by  physiolo* 
gical  authors  ? Is  their  existence  proved  by  observation  or  inspec- 
tion ? If  not,  what  are  the  proofs  fi’om  which  their  existence  has 
been  inferred  ? 

The  existence  of  minute  arteries,  the  open  extremities  of  which 
are  believed  to  pour  out  various  fluids  in  different  tissues  of  the 
human  body,  has  long  been  a favourite  speculation  with  physiolo- 
gical anatomists.  The  decreasing  vessels,  {vasculorum  continuo 
decrescentium  multi  sibique  succedentes  oi'dines,)*  and  exhalant  ori- 
fices of  Boerhaave,  are,  or  should  be  known  to  almost  all.  Haller 
ascribes  to  the  skin,  membranes  of  cavities,  {serous  membranes^ 
ventricles  of  the  brain,  the  chambers  of  the  eye,  the  cells  of  the 
adipose  membrane,  the  vesicles  of  the  lung,  the  cavity  of  the  sto- 
mach and  intestines,  an  abundant  supply  of  these  exhalant  arteries 
or  canals,  which,  according  to  him,  pour  out  a thin,  aqueous,  jelly- 
like  fluid,  which,  in  disease,  or  after  death,  is  converted  into  a wa- 
tery fluid  susceptible  of  coagulation.  The  existence  of  these  ves- 
sels, he  conceives,  is  established  by  the  watery  exudation  which 
appears  in  these  several  parts  after  a good  injection  of  the  ar- 
teries.! 

As  these  minute  canals,  however,  through  which  this  injected 
fluid  is  believed  to  percolate,  have  never  been  seen,  or  rendered 
capable  of  actual  inspection,  their  existence  was  denied  by  Mas- 
cagni, who  ascribed  the  phenomena  of  exhalation  to  the  presence 
of  inorganic  porosities  in  the  arterial  parietes,  through  which  he 
imagined  the  fluids  transuded  to  the  membranes  or  organs,  in  which 

* Haller,  Elementa,  Lib.  ii.  sect.  i.  and  his  Notes  on  Boerhaave,  Praelectiones, 
Tome  II.  p.  245. 

t “ Aqueum  humorem  de  arteriis  perinde  exhalare,  olei  terebinthin®,  ahorumve 
pigmentorum  et  vivi  ai-genti  iter  persuadet,  quod  anatomica  manu  impulsum,  ant  om- 
nino  vivo  in  homine  a consuetis  natm-se  viribus  eo  deductum,  in  ejus  humoris,  qiiam 
vocant  cameram,  depluit.” — Elementa,  Lib.  vii.  sectio  2,  § 1. 


188 


GENERAL  AND  PATUOLOGICAL  ANATOMY. 


they  were  found.  This  mechanism,  which  was  equally  invisible 
with  the  Hallerian,  was,  for  obvious  reasons,  denied  by  Bichat,  who 
resolved  to  reject  every  opinion  not  founded  on  anatomical  obser- 
vation, and  to  determine  the  existence  of  the  exhalants  by  this  evi- 
dence alone.  Obliged,  however,  to  avow  the  difficulty  of  forming 
a distinct  idea  of  a system  of  vessels,  the  extreme  tenuity  of  which 
prevented  them  from  being  seen,  he  undertook  to  attain  his  object 
by  what  he  terms  a rigorous  train  of  reasoning. 

This  consists  in  nothing  more  than  the  effects  observed  to  result 
from  fine  and  successful  injections  of  watery  fluids,  or  of  spirit  of 
turpentine  containing  some  finely  levigated  colouring  matter,  from 
the  phenomena  of  active  hemorrhage,  which  Bichat  considers 
merely  as  exhalation  of  blood  instead  of  serous  fluid,  and  from  a 
multitude  of  considerations  which  are  to  be  unfolded  in  the  course 
of  further  examination  of  the  subject.  In  this  manner  he  believes 
himself  warranted  to  conclude,  that  the  only  things  rigorously  as- 
certained are,  Is^,  The  existence  of  exhalants;  2d,  Their  origin  in 
the  capillary  system  of  the  part  in  which  they  are  distributed ; and, 
3(/,  Their  termination  on  the  surfaces  of  serous  and  mucous  mem- 
branes, and  the  outer  surface  of  the  corion  or  true  skin. 

The  exhalant  vessels,  the  existence,  origin,  and  termination  of 
which  he  thus  proved,  he  distinguished  into  three  classes.  The 
first  contains  those  exhalants  which  are  concerned  in  the  production 
of  the  fluids,  which  are  immediately  removed  from  the  body, — the 
cutaneous  and  the  mucous  exhalants.  The  second  contain  those 
exhalants  which  are  employed  in  the  formation  of  fluids,  which, 
continuing  a given  time  on  various  membranous  surfaces,  are  be- 
lieved to  be  finally  taken  again  into  the  circulation  by  means  of 
absorption.  And  the  third  class  consists  of  the  exhalants  con- 
cerned in  the  process  of  depositing  nutritious  matter  in  the  differ- 
ent tissues  and  organs  of  the  human  frame.  This  arrangement  is 
more  distinctly  seen  in  the  following  table. 


1.  Exterior,  opening  on  natural  surfaces  or  canals, 

. 2.  Interior,  opening  on  membranes,  or  within  cellular 
textures. 

^3.  Nutritious. 


I Cutaneous, 
j Mucous. 

! Serous. 
Synovial. 
Cellular. 
Medullary. 


Each  organic  tissue  is  in  this  system  supposed  to  have  its  appro- 
priate exhalant  arteries,  from  which  it  derives  the  material  requi- 
site for  its  nutrition. 


SYSTEM  OF  EXHALANTS. 


189 


It  is  undeniable  that  this  arrangement  is  at  once  clear,  and  "pos- 
sesses a sort  of  interesting  regularity,  which  would  prompt  the  wish, 
that  the  existence  of  these  vessels  was  actually  demonstrated  with 
certainty.  It  is  evident,  however,  that  the  regularity  of  arrange- 
ment is  the  only  advantage  which  it  possesses  over  the  views  of 
those  authors,  whose  method  and  opinions  Bichat  professed  not  to 
follow.  The  existence  of  exhalants  is  as  little  proved  in  the  ri- 
gorous reasoning  of  Bichat,  as  in  the  fanciful  theories  of  Boerhaave, 
the  generalizing  conclusions  of  Haller,  or  the  bold  supposition  of 
lateral  porosities  by  Mascagni.  This  defect  in  his  system  has 
therefore  been  recognised  by  Magendie  and  Bedard,  the  first 
of  whom,  though  he  admits  the  existence  of  exhalation  as  a pro- 
cess of  the  living  body,  allows  that  no  explanation  of  its  mecha- 
nism or  material  cause  has  been  given,  and  asserts  that  Bichat  has 
created  the  system  of  vessels  termed  exhalants ; — while  the  second 
thinks  that  anatomical  observation  furnishes  no  evidence  of  their 
existence. 

The  colourless  capillaries,  he  observes,  which  are  admitted  by 
all,  and  the  existence  of  which  is  satisfactorily  established  by  the 
well-known  experiment  of  Bleuland,  proves  nothing  whatever  con- 
cerning the  existence  of  exhalant  vessels ; for  these  colourless  ar- 
teries are  observed  to  terminate  in  colourless  veins,  and  there  is  no 
proof  hitherto  adduced  of  their  proceeding  further,  or  terminating 
by  open  mouths.  He  admits  that  the  fact  of  exhalation  in  the 
living  body,  of  nutrition,  of  transudation  by  arterial  extremities, 
shows  that  these  extremities  possess  openings  through  which  the 
fluids  of  exhalation,  the  materials  of  nutrition,  and  the  matter  of 
injection  escape.  But  whether  these  openings  are  found  at  the 
point,  at  which  the  capillary  arteries  are  continuous  with  veins,  or 
belong  to  a distinct  order  of  vessels  continued  beyond  these  arte- 
ries, is  a question  which  observation  has  not  yet  determined,  and 
which  it  perhaps  is  unable  to  determine.  Meanwhile,  that  the  ex- 
istence of  a process  such  as  exhalation  is  believed  to  be,  is  carried 
on  in  the  animal  body,  appears  to  be  proved  by  the  phenomena 
of  endosmosis  and  exosmosis.  Such  is  the  present  state  of  know- 
ledge in  relation  to  the  existence  of  exhalant  arteries.  While 
the  process  of  exhalation  is  admitted  and  believed,  we  must  avow, 
as  Cruikshank  did  long  ago,  that  we  are  unable  to  prove  satisfac- 
torily the  existence  of  any  set  of  vessels,  or  any  mechanism  by  which 
it  might  be  accomplished. 


190 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


This  difficulty,  however,  need  not  prevent  us  from  observing, 
that  this  is  the  proper  place  for  noticing  those  morbid  changes, 
which  are  referred  to  the  process  of  exhalation. 

Section  II. 

The  exhalations,  properly  so  called,  may  be  morbidly  augment- 
ed or  diminished,  or  quite  changed. 

1.  The  best  examples  of  morbid  increase  of  exhalation  is  con- 
ceived to  be  found  in  those  of  the  serous  membranes,  giving  rise 
to  the  disease  termed  dropsy,  {Hydrops.)  It  is  most  frequent  in 
the  peritoneum  and  in  the  general  cellular  membrane ; less  so  in 
the  pleura  and  pericardium,  and  in  the  arachnoid  membrane  or  its 
divisions.  In  a local  form  it  is  very  frequent  in  the  vaginal  coat 
of  the  testicle.  Recent  observations  on  this  morbid  change,  and  on 
the  state  of  the  system  when  under  its  influence,  lead  to  the  con- 
clusion, that  it  is  rarely  a primary  process,  but  is  generally  to  be 
considered  as  the  effect  of  another, — as  the  symptom  of  a peculiar 
condition  of  the  system  of  capillary  arteries  going  to  the  tissue 
which  is  the  immediate  seat  of  exhalation. 

The  conditions  of  the  capillary  system  in  which  exhalation  is 
preternaturally  augmented  are  referable  to  two  general  heads. 
The  first  of  these  is  the  state  of  distension  which  takes  place  during 
inflammation,  fever,  &c.  The  second  is  the  distension  w'hich  re- 
sults from  any  mechanical  impediment  to  the  free  motion  of  the 
blood  in  a venous  trunk  or  trunks,  or  in  the  arteries. 

a.  That  the  distended  or  overloaded  state  of  the  capillaries  which 
occurs  during  inflammation  may  cause  a great  and  disproportionate 
increase  in  the  fluid  exhaled,  is  established  by  the  phenomena  of 
inflammation  of  the  filamentous  tissue,  and  especially  of  the  serous 
membranes.  In  the  former,  oedema  and  anasarca  are  results  by  no 
means  unfrequent.  In  the  latter,  one  of  the  first  effects  of  inflam- 
mation, under  certain  circumstances,  is  effusion  of  fluid  more  or 
less  copious,  and  containing  various  proportions  of  coagulable  mat- 
ter. If  the  proportion  of  the  latter  be  great,  its  coagulation  forms 
organizable  lymph,  which  is  the  medium  of  adhesion,  while  the  se- 
rous part  disappears,  apparently  by  absorption.  If  it  be  small,  its 
coagulation  gives  rise  to  mere  loose  flakes,  which,  with  the  con- 
stant increase  of  the  quantity  of  fluid  effused,  are  unable  to  main- 
tain their  attachment  to  any  part  of  the  membrane ; while  the  thin 


SYSTEM  OF  EXHALAJ^TS. 


191 


serous  part  is  so  copious,  that  as  it  is  not  removed  by  the  veins  and 
lymphatics,  it  remains  in  the  form  of  a serous,  a sero-sanguine,  or 
a sero-purulent  fluid,  constituting  genuine  dropsy.  The  detailed 
examination  of  this  morbid  accumulation  belongs  to  the  chapter  on 
the  serous  membranes. 

That  the  capillary  distension  which  takes  place  in  fever  is  a fre- 
quent cause  of  anormal  exhalation,  is  shown  by  the  collections  of 
limpid  serum  often  found  in  the  brain  and  spinal  chord,  by  that 
sometimes  seen  in  the  pericardium,  and  by  the  brownish  watery 
fluid  often  found  in  the  pleura  in  the  bodies  of  persons  cut  off  by 
any  of  the  varieties  of  that  disease. 

/3.  The  influence  of  impediment  to  the  return  of  the  venous  blood 
in  the  production  of  extraordinary  effusion  has  been  known  from 
the  earliest  periods  of  medicine.  In  proof  of  this  I shall  not  ad- 
duce the  experiment  of  Lower,  who  by  tying  the  vena  cava  in  a dog, 
produced  dropsy  in  a few  hours ; for  the  injury  in  such  a case  may 
produce  inflammation  of  the  peritoneum,  and  consequent  effusion  ; 
and  Hewson  has  justly  objected  to  its  competency,  that  the  ligature 
might  have  included  lymphatics  along  with  the  venous  trunk.* 
Nor  is  it  requisite  to  notice  the  experiments  of  Peyer,  Bontekoe, 
and  others.  It  is  sufficient  to  say,  that  the  fact  is  established  by 
the  eflfects  of  deranged  circulation,  as  they  take  place,  in  veins ; 
secondly^  in  arteries ; and,  thirdly,  in  both  sets  of  vessels  jointly,  or 
in  the  capillary  system. 

To  the  first  head  are  to  be  referred  tumour’s  in  the  vicinity,  or 
affecting  the  substance  of  veins ; various  diseases  of  the  right  au- 
ricle and  right  ventricle  of  the  heart ; hard  disorganization  or  tu- 
bercles of  the  liver ; cirrhosis  of  the  liver  ; hepatization  or  tuber- 
cular disorganization  of  the  lungs  ; hard  disorganization  or  scirrhus 
of  the  pancreas ; induration  and  hj-pertrophy  or  tubercles  of  the 
spleen ; and  compression  of  the  ascending  cava  by  the  gravid 
womb  during  the  latter  stage  of  pregnancy.  Of  a more  local  cha- 
racter are  the  oedematous  swellings  which  appear  in  the  neighbour- 
hood of  tumours  and  abscesses.  Thus  in  abscess,  aneurism,  or  tu- 
mom’  of  the  arm-pit,  and  in  scirrhus  or  cancer  of  the  female  breast, 
the  whole  arm  becomes  oedematous  from  the  top  of  the  shoidder  to 
the  tip  of  the  fingers.  One  of  the  earliest  symptoms  of  lumbar  ab- 
scess is  in  some  instances  an  oedematous  enlargement  of  the  leg  of 
the  side  on  which  the  abscess  takes  place ; and  almost  all  deep- 

* Experimental  Inquiries,  Part  ii.  by  William  Hewson,  F.R.S.  London,  177-1.  p.  142. 


192 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


seated  collections  of  matter  give  rise  to  considerable  oedema  of  the 
superior  cellular  membrane  and  skin. 

The  operation  of  the  several  circumstances  now  mentioned, 
though  well  understood  by  many  pathologists,  has  been  happily 
illustrated  by  M.  Bouillaud,  who  has  shown  that  in  many  instances 
tumours  in  the  neighbourhood  of  venous  trunks  compress  them  so 
much,  as  to  produce  obliteration  of  their  canal.  The  interior  of  the 
vessel  is  then  occupied  with  a clot  of  blood,  solid,  fibrinous,  and 
more  or  less  friable,  manifestly  produced  by  the  blood  being  stop- 
ped in  its  course  along  the  vein.*  To  obstruction  of  this  descrip- 
tion M.  Bouillaud  traced  several  instances  of  partial  dropsy. 

Of  the  influence  of  the  second  cause  in  producing  dropsical  ef- 
fusion, we  have  examples  in  that  which  results  from  enlargement  of 
the  right  side  of  the  heart,  ossification  and  contraction  of  the  mitral 
or  semilunar  valves,  ossification  of  the  coronary  arteries,  aneurism 
of  the  aorta  or  innominata,  or  even  of  the  coeliac  artery,  all  of  which 
give  rise  to  more  or  less  serous  effusion  in  the  pleura,  or  a symp- 
tomatic dropsy  of  the  chest. 

The  third  condition  is  perhaps  the  most  common  origin  of  the 
symptomatic  or  secondary  dropsies.  Whatever  retards  the  free 
circulation  of  blood  through  the  minute  arteries  and  veins  of  any 
organ  or  texture  will  produce  one  or  other  of  the  following  efiects  ; 
viz.  inflammation,  injection  with  effusion  of  red  blood,  or  efiPusion 
of  serous  fluid  from  the  exhalants,  according  to  circumstances.  In 
subjects  where  the  structure  of  the  parts  is  somewhat  lax  and  yield- 
ing, the  last  will  be  the  most  likely  result ; and  it  may  be  regard- 
ed as  tbe  mere  consequence  of  tbe  mechanical  obstruction  which 
the  blood  encounters  in  its  transit  from  the  capillary  vessels  to  the 
larger  trunks.  “ The  compression  of  a vein,”  it  is  judiciously  re- 
marked by  Hewson,  “ may,  by  stopping  tbe  return  of  the  blood, 
not  only  distend  the  small  veins,  but  the  small  arteries ; and  the 
exhalants  may  be  so  dilated,  or  so  stimulated  as  to  secrete  more 
fluid  than  they  did  naturally.”f  It  is  in  general,  however,  a re- 
mote consequence,  and  is  observed  to  take  place  only  after  the 
cause  of  deranged  circulation  has  subsisted  for  some  time.  Thus 
tumours,  tubercles,  and  other  foreign  growths  of  the  brain  give 
rise  to  watery  effusion  within  its  ventricles.  Hepatization  and  tu- 

■*  De  I’obliteration  des  veines  et  de  son  influence  sur  la  formation  des  hydropisies 
partielles,  &c.  Par  M.  Bouillaud.  Interne  des  hopitaux  civils  de  Paris. — Archives  Ge- 
nerates de  Medecine,  Tome  II.  p.  188. 

•f-  Experimental  Inquiries,  Part  ii.  &c.  p.  142. 


SYSTEM  OF  EXHALANTS. 


193 


bercles  of  the  lungs,  chronic  inflammation  of  the  bronchial  mem- 
brane, ossification,  cancer,  tubercles,  and  other  morbid  changes  in 
the  pleura,  produce  a symptomatic  water  within  the  chest.  And  in 
dysentery,  tubercular  disease  of  the  peritoneum,  and  enlargement 
of  the  mesenteric  glands,  {tabes  mesenterica),  sy^mptomatic  ascites  is 
a very  frequent  occurrence. 

2.  Unusual  increase  of  exhalation  may  take  place  in  the  syno- 
vial membranes,  either  articular  or  tendinous.  In  the  former  case 
it  constitutes  one  form  of  disease  of  the  joints,  to  which  perhaps  the 
name  of  hydrarthrus  ought  to  be  restricted.  To  this  head  also  be- 
longs the  efliision  which  takes  place  in  articular  rheumatism  and  in 
synovial  rheumatism.  In  the  latter,  inordinate  exhalation  produ- 
cing effusion  forms  the  elastic  hemispheroidal  tumour  known  under 
the  denomination  of  ganglion. 

3.  Diminution  of  exhalation  is  rare,  unless  in  consequence  of  an 
unnatural  augmentation  of  it  elsewhere. 

4.  Hemorrhage.  The  only  example  of  complete  change  of  ex- 
halation is  that  termed  by  Bichat  preternatural  exhalations.,  and 
the  most  common  of  these  is  when  the  matter  exhaled  consists  not 
of  the  usual  watery  fluid,  but  of  pure  blood,  constituting  several 
forms  of  the  disease  termed  hemorrhage.  This  bloody  exhalation 
may  take  place  either  in  the  exhalations  termed  excrementitial, 
or  in  those  termed  recrementitial, 

«,  To  the  first  head  are  to  be  referred  those  hemorrhages  from 
the  skin  which  are  sometimes  observed,  and  those  from  mucous 
membranes,  which  are  very  frequent,  during  congestion  of  their  ca- 
pillary system.  In  the  lungs  for  example,  nothing  is  more  com- 
mon than  exudation  of  blood  from  the  bronchial  membrane  during 
catarrh  or  bronchial  inflammation.  In  such  circumstances  it  is  ge- 
nerally small  in  quantity,  {heemoptoe,)  and  unlike  the  copious  and 
irresistible  discharge  of  pulmonary  apoplexy. 

It  is  still  more  distinct  in  haemoptysis,  in  which  considerable  quan- 
tities of  blood  issue  from,  the  surface  of  the  bronchial  membrane 
without  breach  or  laceration,  and  consequently  from  the  orifices  of 
vessels  by  a process  analogous  to  exhalation.  (Bichat.)  Is  it  also 
by  exhalation  that  the  copious  discharge  of  pulmonary  apoplexy 
takes  place  ? On  this  point  facts  are  wanting. 

In  hemorrhage  from  any  point  of  the  gastro-intestinal  membrane 
the  blood  is  exhaled  in  the  same  manner.  The  researches  of  Por- 

N 


194 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


tal,*  and  Abernetliyf  especially,  as  well  as  those  of  Bichat,  esta- 
blish the  point  as  to  the  stomach  and  small  intestines  in  li(Bmate- 
mesis  and  rnelcBna.  In  dysentery  the  blood,  however  copious  it 
may  appear,  oozes  from  a large  extent  of  the  surface  of  the  lower 
end  of  the  ileum,  and  from  that  of  the  colon,  without  ulceration  or 
gangrene,  and  evidently  from  the  vessels  of  the  villous  membrane, 
which  during  health  secrete  mucous  and  intestinal  fluid.  The  same 
is  to  be  understood  of  hemorrhages  from  the  rectum,  indiscrimi- 
nately known  under  the  name  of  Immorrhois  and  hemorrhoidal  dis- 
charges, and  erroneously  supposed  to  proceed,  in  all  cases,  from  the 
hemorrhoidal  veins.  The  true  source  of  many  of  those  bloody 
discharges  is  the  vessels  of  the  villous  membrane  of  the  bowel, 
which  is  usually  observed  to  be  reddened  or  embrowned,  thicken- 
ed, softened,  and  covered  with  blood- coloured  mucus. 

In  the  exhalants  of  the  genito -urinary  mucous  system  the  same 
condition  takes  place.  Hemorrhage  from  the  kidney,  unless  caused 
by  calculus,  is  the  result  of  exhalation.  Menstruation,  both  in  the 
sound  state  and  when  excessive,  is  equally  so.  (William  Hunter 
apud  Cruikshank,  I Bichat.) 

In  all  these  cases  of  hemorrhage  two  conditions  of  the  capillary 
and  exhalant  system  may  be  remarked.  First,  In  the  capillaries 
an  unusual  proportion  of  blood  is  accumulated,  so  that  the  small 
ones  conveying  red  blood  become  large  and  distended,  and  those 
conveying  the  colourless  part  are  injected  with  red  blood.  Second- 
ly/, After  this  state  has  continued  for  some  time,  red  blood  is  ob- 
served to  ooze  in  minute  drops  from  the  surface  of  the  membrane, 
and  progressively  to  increase  in  quantity  and  superficial  extent. 

* Memoires  sur  la  Nature  et  la  Traitement  cle  plusieurs  Maladies.  Par  M.  Antoine 
Portal.  Tome  II.  Paris,  1800,  p.  108. 

f On  the  Constitutional  Origin  and  Treatment  of  Local  Diseases.  By  John  Aber- 
nethy.  London,  1811. 

^ “ It  happened  that  a woman  died  when  her  menses  were  flowing.  Dr  Hunter 
examined  the  internal  surface  of  the  uterus,  found  it  exceedingly  red  and  loaded  mth 
Ijlood  ; that  the  principal  redness  was  from  the  distended  and  convoluting  arteries. 
He  pressed  forward  the  blood,  wliich  was  fluid,  and  which,  he  asserted,  never  coagu- 
lated, and  saw  it  appear  on  the  surface  near  the  extremities  of  these  arteries.  As  this 
discharge  happened  instantly,  and  from  the  gentlest  pressure  of  the  finger,  it  could  not 
be  transudation,  which  always  requires  time  ; it  could  not  be  rupture  of  vessel.  I 
have  had  several  opportunities  of  repeating  this  experiment,  which  always  succeeded 
in  the  same  manner.” — The  Anatomy  of  the  Absorbing  Vessels  of  the  Human  Body, 
by  William  Cruikshank.  London,  1786  and  1790,  Chapter  xi.  p.  55;  The  same  fact 
has  been  satisfactorily  established  by  observation  in  cases  of  prolapsed  or  retroverted 
uterus,  when  the  blood  is  seen  oozing  from  the  villous  surface  of  the  organ. 

i 


SYSTEM  OF  EXHALANTS. 


195 


The  cause  of  this  accumulation  and  consequent  exudation  is  not 
known.  To  assert,  as  Bichat  has  done,  that  a change  in  the  or- 
ganic sensibility  of  the  exhalants  opens  a passge  through  them  to 
are  unchanged  blood,  is  to  describe  the  fact  in  a different  mode 
without  explaining  its  reason.  The  hemorrhagic  effort  of  Stahl, 
and  the  error  loci  of  Boerhaave,  are  equally  true  and  not  less  in- 
telligible. 

/3.  In  the  recrementitial  exhalants,  and  first  in  those  of  transpa- 
rent or  serous  membranes,  though  less  frequently,  the  same  anor- 
mal  condition  may  be  often  recognised.  In  the  pleura  or  the  pe- 
ricardium, and  in  the  peritoneum,  it  is  not  unusual  to  find  bloody 
fluids  of  various  tints,  evidently  the  result  of  exhalation.  The  fluid 
effused  may  be  simply  bloody  serum  if  little  blood  is  exhaled,  very 
red  if  more  is  poured  forth,  or  even,  as  I shall  show  afterwards,  it 
may  be  pure  blood.  In  several  of  the  cases  in  which  blood  is  found 
in  the  ventricles  of  the  brain,  it  cannot  be  traced  to  any  other  source 
save  the  exhalants  of  the  choroid  plexus ; and  blood  may  be  showm 
to  be  effused  occasionally  from  the  outer  division  of  the  arachnoid 
membrane,  and  also  fi’om  that  which  covers  the  spinal  chord. 

In  each  of  these  cases,  whether  the  fluid  is  merely  sanguinolent 
or  is  pure  blood,  it  issues  from  the  same  vessels  which,  in  the 
healthy  state  of  the  membrane,  prepare  its  proper  secretions.  No 
rupture  or  breach  can  be  recognised  by  the  most  accurate  scrutiny. 
Bichat  is  disposed  to  view  the  sanguinolent  effusions  as  the  effect 
of  inflammation,  acute  or  chronic,  or  like  dropsy,  as  the  consequence 
of  organic  diseasa  The  few  cases  hitherto  acciu'ately  recorded 
show,  that,  whatever  be  the  remote  cause,  the  state  of  the  capilla- 
ries of  the  serous  membranes  is  much  the  same  as  those  of  mucous 
surfaces  under  similar  circumstances. 

I formerly  spoke  of  hemorrhage  occurring  in  cellular  membrane. 
The  blood  is  in  this  case  derived  from  the  exhalants  of  that  tissue 
exactly  as  it  issues  from  those  of  the  serous  membranes.  As  an 
active  hemorrhage,  it  is  not  unfrequent  in  severe  ■phlegmon,  and  in 
the  bloody  abscess,  as  it  is  named,  with  which  the  practical  surgeon 
is  familiar.  As  a passive  hemorrhage,  it  occurs  in  land-scurvy 
and  in  sea-scurvy. 

In  some  instances  the  synovial  membranes,  both  in  joints  and  in 
the  tendinous  sheaths,  are  found  to  contain  blood  or  bloody  fluid, 
which  must  have  issued  from  their  exhalant  arteries. 

5.  Elephantia.  Another  example  still  of  disease  to  be  referred 
to  the  head  of  anormal  exhalation,  is  presented  in  the  unshapely 


196 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


enlargement  of  a member,  which  has  been  termed  elephant-leg, 
(^Elephantiasis,)  the  glandular  disease  of  Barbadoes  by  Hendy,  and 
which  is  known  in  the  East  under  the  name  of  the  Cochin-leg. 
Though  most  frequently  seen  in  the  lower  extremity,  it  is  not  pe- 
culiar to  this  part ; and  authentic  instances  of  its  occurrence  in  the 
upper  extremity  are  not  wanting.  Thus,  Fabricius  Hildanus  re- 
lates a case  of  enlargement  of  the  arm,  {brachium  monstrosum,)  in 
a poor  woman  of  Champs  d’Or.* * * §  Henseler  records  and  delineates 
an  example  of  the  same  in  the  arm  of  a woman  at  Ulm  and 
mentions  an  instance  in  the  arm  and  leg  at  once  in  a woman  at 
Dresden.  And  an  instance  not  dissimilar  in  the  person  of  a Hin- 
doo was  given  not  long  ago  by  Mr  Kennedy  of  Madras.^  Ac- 
cording to  Dr  Graves,  it  is  most  frequent  in  the  upper  extremity 
in  Ireland.§  Cases  of  the  same  kind  from  Caithness,  Ross-shire, 
and,  if  I remember  right,  from  the  Shetland  Islands,  are  occa- 
sionally seen  here.  The  instances  in  the  lower  extremity  are  doubt- 
less most  common  in  tropical  countries. 

Though  it  has  been  the  general  pi’actice  since  the  time  of  Hendy 
to  regard  this  disease  as  resulting  from  obstruction  of  the  lympha- 
tic vessels  and  glands,  the  phenomena  of  its  formation  and  progress, 
with  those  of  its  morbid  anatomy,  show  clearly,  I think,  that  the 
inordinate  enlargement  arises  from  a quantity  of  albuminous  or 
sero-albuminous  fluid,  being  effused  from  the  exhalants  into  the 
cellular  tissue  of  the  limb,  and  which  is  not  removed  by  adequate 
absorption.  That  the  enlargement  is  effected  in  this  manner,  and 
that  the  effusion  is  the  result  of  some  form  of  the  process  of  inflam- 
mation recurring  periodically,  may  be  inferred  from  the  following- 
considerations  : — 

Is^,  In  all  the  cases  of  the  disease  which  have  been  accurately 
observed,  the  first  attack  of  enlargement  is  preceded  by  general  in- 
flammatory action  affecting  the  whole  limb,  described  as  similar  to 
rose  {erysipelas^  and  distinguished  by  heat,  pain,  general  swelling, 
and  more  or  less  redness.  Of  these  symptoms  the  effusion  and 
enlargement  are  a sort  of  natural  crisis. 

2d,  In  most,  if  not  all  the  cases,  this  inflammatory  attack  recurs 

* Joaniiis  Henseler,  Historia  Bvachii  Prcetumicli.  Extat  in  Haller  Disputat.  Chi- 
rurgicis,  Vol.  V.  p.  445. 

-f-  Centuria  IV.  Observ.  69,  with  a good  wooden  cut. 

:j;  Case  of  diseased  arm,  by  Alexander  Kennedy,  Esq.  Edinburgh  Medical  and  Sur- 
gical Journal,  Vol.  XIII.  p.  54. 

§ Dublin  Hospital  Reports,  Vol.  IV.  Clinical  Observations,  by  Robert  Graves, 

M.  D. 


SYSTEM  OF  EXHALAOTS. 


197 


after  certain  intervals,  which  are  progressively  shorter,  and  always 
with  the  effect  of  increasing  the  enlargement. 

M,  In  all  the  cases  in  which  the  enlarged  limb  has  been  ex- 
amined by  dissection,  the  subcutaneous  and  intermuscular  filamen- 
tous tissue  is  hardened,  thickened,  and  condensed,  and  contains  a 
quantity  of  granular  matter,  viscid  and  gelatinous  in  consistence, 
but  like  fat  in  appearance.  This  has  not  been  analyzed  ; but  little 
doubt  can  be  entertained  that  it  contains  a good  proportion  of  al- 
buminous matter.  That  this  is  the  essential  change,  is  established 
by  the  testimony  of  many  observers.  (Jaegerschmidt,  Henseler, 
Kennedy,  Graves,  Hull.)  The  distension  of  the  skin,  the  enlarge- 
ment of  its  papillae,  the  slender  blanched  appearance  of  the  muscles, 
and  the  enlargement  of  the  inguinal  glands,  are  effects  only  of  the 
state  of  the  subcutaneous  and  intermuscular  cellular  tissue.  In 
short,  until  new  facts  he  adduced,  the  description  given  by  Dr 
Graves,  and  the  case  of  Mr  Hull,  establish  the  inference,  that  the 
elephantine  enlargement  of  the  extremities  is  the  result  of  gelati- 
nous or  albuminous  exudation  from  the  arteries  of  the  subcutane- 
ous filamentous  tissue.  Dr  Musgrave  considers  it  as  migratory  in- 
flammation. 

6.  Accidental  Development  or  Morbid  Formation  of  the  Exha~ 
lant  Si/stem.  In  several  instances  a process  of  exhalation  takes 
place  in  certain  textures  in  which  it  did  not  originally  exist,  at 
least  under  the  same  form ; or  a process  of  exhalation  may  go  on 
without  a corresponding  one  of  removal  by  absorption.  Of  this 
abnormal  development  of  the  exhalant  system,  which  constitutes 
the  tumours  called  encysted,  (tumores  cystici,  tunicati,  Salzmann, 
Heister,)  several  varieties  have  been  noticed  by  practical  authors, 
as  Ingrassias,  Severinus,  Tagault,  Pare,  Schelhammer,  Astruc, 
Meek’ren,  Heister,  &c. ; and^the  division  of  Celsus  into  meliceris^ 
atheroma^  and  steatoma,  has  been  repeated  by  the  generality  of 
writers,  from  Hildanus  to  Monteggia,  Abernethy,  and  Boyer. 
This  division,  to  which  I have  already  adverted  in  speaking  of  en- 
cysted tumours  in  the  cellular  tissue,  is  nevertheless  imperfect;  and 
indeed  no  distinct  and  connected  arrangement  of  all  the  varieties 
of  encysted  tumour  has  yet  been  given,  unless  the  seventh  genus 
of  the  system  of  Plenck  be  entitled  to  this  charactei’.*  Without 
attempting  to  specify  the  individual  defects  of  the  classification  of 

* Joseph!  Jac.  Plenck,  Novum  Systema  Tumomm,  quo  hi  morbi  in  sua  genera  et 
species  rediguntur.  ViennEc,  1707. 


198 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


this  surgeon,  I conceive  I am  justified  in  asserting,  that  one  more 
strictly  pathological  may  be  given. 

Considered  as  examples  of  inordinate  exhalation  without  corre- 
sponding absorption,  the  species  of  encysted  tumour  may  be  enu- 
merated in  the  following  order. 

a.  Acephalo-cysts  or  Hydatids  are  cysts  secreting  limpid  watery 
fluid.  They  have  been  commonly  believed  to  be  living  animals.  And 
since  the  full  account  of  their  origin  and  nature  by  Laennec,  this 
opinion  has  been  almost  universally  received.  They  therefore  do  not 
properly  belong  to  the  present  head,  and  should  be  arranged  with 
that  of  parasitical  productions.  By  Plenck  the  hydatid  is  regarded 
as  a variety  of  the  next  species — the  liyyroma.  Combined  with 
atheromatous  or  steatoraatous  matter,  hydatid-cysts  are  occasionally 
found  in  the  subcutaneous  cellular  tissue.  (Heunden  apud  Tyson, 
sixty  hydatids  in  a cyst  in  the  neck.) 

/3.  Hygroma.  The  serous  cyst.  Cysts  secreting  sero-puruient, 
or  even  a sero-sanguine  fluid.  This  epithet  Plenck  applies  to  a 
spherical  tumour  containing  coagulable  lymph,  evidently  meaning 
fluid ; and  regards  it  as  differing  from  the  hydatid  in  size  only, 
and  from  lymphatic  (serous)  tumours,  by  the  possession  of  a mem- 
branous covering,  or  proper  cyst.  It  is  more  expedient  to  apply 
it  to  all  encysted  tumours  not  manifestly  hydatoid,  which  contain 
serous,  sero-purulent,  or  viscid  glairy  fluid,  or  even  reddish  serum, 
in  whatever  situation  they  are  found.  The  best  example  of  this 
tumour  is  the  cyst  or  cysts  often  found  in  the  female  ovary,  in 
which  they  vary  in  size,  and  in  the  colour  and  consistence  of  their 
contents,  from  mere  serum,  with  more  or  less  albumen,  to  reddish, 
bloody,  or  even  tar-like  fluid.  They  occur  in  the  brain,  e.  g.  its  hemi- 
sphere,* and  in  the  pineal  gland.  The  cases  delineated  by  Hooper 
as  vesicles  and  encysted  tumour,  are  evidently  of  this  description. 
Plenck  admits  the  serous  hygroma  in  the  cellular  membrane. 

y.  Hcematoma.  A cyst  secreting,  or  containing  a bloody  fluid. 
Severinus,  Ingrassias,  and  moi’e  recently  Monteggia,  John  Peter. 
Frank,  Scarpa,  and  Montini,  mention  examples  of  globular  or 
spheroidal  tumours  containing  blood  more  or  less  fluid  within  a 
membranous  sac  or  covering.  Under  the  name  of  bloody  abscess., 
indeed,  Severinusf  assembles  aneurisms,  as  well  as  the  blood-cyst. 

* The  Morbid  Anatomy  of  the  Human  Brain.  By  Robert  Hooper,  M.D.  Plate 
XIII.  XII.  Fig.  8.  and  XIV. 

-f-  Miirci  Aurelii  Severini  apud  Neapolitanos  Medici  ac  Philosopliii  Regii,  de  Ab- 
scessnum  Recondita  Natura,  Libri  viii.  Lugduni  Batavorum,  1724.  Lib.  iv.  cap.  vii. 


SYSTEM  OF  EXHALAXTS. 


199 


Frank,  I believe,  first  (1786)  distinguished  one  of  these  tumours 
on  the  chin  of  a girl  of  nine,  of  the  size  and  shape  of  a goose-egg, 
as  of  the  encysted  kind,  and  first  applied  to  it  the  denomination  of 
hcsmatoma*  About  the  same  time  (1789)  Monteggia  described 
the  hloody  tumour  similar  to  that  of  Severinus,  as  occurring  in  the 
arm-pit,  and  attaining  a great  size,  and,  when  opened,  speedily  prov- 
ing fatal.!  An  example  of  the  disease  was  afterwards  seen  hy  Scarpa 
in  the  same  situation  in  the  person  of  a priest  about  fifty,  in  the  thy- 
roid gland  and  neck  of  other  subjects,  and  in  the  breast  of  a lady 
and  Montini  saw  it  in  the  thigh  of  a woman  in  childbed  at  Lodi.§ 

An  example  of  this  species  of  tumour  was  in  1843  given  by 
the  late  Dr  Hannay  of  Glasgow.  It  occurred  in  the  lateral  and 
posterior  region  of  the  neck  of  a child  of  fourteen  months,  in  other 
respects  healthy.  It  appeared  first  on  the  left  side  of  the  neck, 
half-way  between  the  jaw  and  collar-bone,  in  the  form  of  a small 
hard  body  about  the  size  of  a gooseberry.  It  remained  stationary 
for  months.  When  seen  by  Dr  Hannay,  it  had  attained  the  size 
of  a goose’s  egg,  consisted  of  two  or  more  lobules,  was  smooth, 
something  glistening,  and  of  a very  indistinct  shade  of  blue  or  ve- 
nous blood  colour.  The  lonw  diameter  was  horizontal.  It  was 

O 

elastic,  and  gave  a sense  of  fluctuation  ; and  touching  or  handling 
seemed  to  cause  pain.  It  was  punctured  by  the  lancet,  and  three 
ounces  of  grumous  but  fluid  blood  were  discharged.  After  this  the 
cyst  seems  to  have  contracted. 

Dr  Hannay  adds,  that  previous  to  this  he  had  seen  four  cases. 
Of  these,  one  was  presented  by  Mr  Brookes  to  his  pupils  as  a case 
of  abscess;  and  some  alarm  was  caused,  when  the  punctm’e  by  the 
lancet  was  followed  by  blood  apparently  pure.  Against  mistakes  of 
this  kind,  if  not  to  be  obviated,  surgeons  would  be  prepared,  by  in- 
forming themselves  of  the  nature  of  the  hcEmatoma  or  blood-cyst. 
Of  the  other  three  cases.  Dr  Hannay  had  seen  two  within  six 
months ; one  in  an  infant,  the  other  in  a woman  between  forty  and 
fifty  years  of  age.|| 

* Joannis  Petri  Frank,  Med.  Clinic,  in  Ticinensi  Academia,  Prof.  Discursus  Aca- 
demic. mense  Junii  1786,  habitus,  Observationem  de  Haematomate,  &c.  exhibens- 
Delectus,  Vol.  III.  Ticini,  1787. 

t Monteggia,  Fasciculi  Pathol,  p.  88.  Mediolani,  1789. 

X Treatise  on  the  Anatomy,  &c.  Appendix,  p.  456.  See  also  Richter  de  mro  iu- 
more  mammm.  Works  of  Else,  and  J.  E.  Pohl  de  Varice,  § XI. 

§ Montini,  Saggio  di  Osservazioni  et  Riflessioni  Chirurgico-pratiche.  Lodi,  1803. 

II  Pathological  Gleanings  ; or  Cases  in  Dispensary  Practice.  By  A.  J.  Hannay,  M.  D. 
&c.  Edinburgh  Medical  and  Surgical  Journal,  Vol.  LX.  p.  319,  October  1843. 


200 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


From  tlie  united  testimony  of  these  observers,  it  appears  that 
the  blood-cyst  (Jicematoma,)  is  a tumour  consisting  of  a membi’a- 
nous  sac,  the  inner  surface  of  which  is  liberally  supplied  with  blood- 
vessels, from  which  blood,  or  a bloody  fluid,  is  incessantly  oozing 
or  distilling  by  exhalation.  In  some  instances  this  fluid  contains 
a proportion  of  flbrin  sufficient  to  effect  coagulation  ; and  the  in- 
terior of  the  cyst  then  resembles  the  spleen  or  a mass  of  clotted 
blood.  From  aneurism  it  may  be  distinguished  by  the  following 
marks  ; that  it  does  not  throb  ; that  it  contains  a fluid  ; that  it  is 
surrounded  by  bluish  tortuous  veins  ; and  that  it  is  dark  or  purple- 
coloured,  while  the  investing  skin  is  transparent.  When  seated  in 
the  neck,  however,  near  the  carotid  artery,  it  may  derive  from  it, 
or  from  the  subclavian,  a pulsating  motion,  which  may  give  it  the 
appearance  of  aneurism. 

There  is  no  reason  to  believe  that  these  tumours  are  in  any  way 
malignant,  or  of  the  character  of  heterologous  growths.  They 
seem  to  be  cysts,  the  inner  surface  of  which  secretes  either  blood 
or  a bloody  liquid  for  some  time,  until  by  their  size  and  position 
they  cause  inconvenience.  When  the  fluid  has  been  evacuated, 
the  cyst  contracts,  its  opposite  walls  adhere,  and  the  action  ceases. 
The  ordinary  locality  of  Immatoma  is  easily  understood  from 
what  has  been  already  said.  It  occurs  most  usually  in  the  filamen- 
tous tissue  of  the  arm-pit  and  neck,  in  the  substance  of  the  thyroid 
gland,  and  at  the  knee.  (Monteggia.)  Zeller  describes  it  as  it 
appears  in  the  brain  of  infants,  under  the  name  of  cephalcematoma. 
Dr  Hooper  has  represented  an  example  of  what  he  refers  to  this 
head  in  his  tenth  engraving.  But  from  the  description,  the  justice 
of  this  appears  questionable.*  It  is  also  mentioned  by  Dr  Monro.f 
h.  Meliceris.  An  indolent  tumour,  generally  small,  with  smooth 
uniform  surface,  communicating  a sense  of  fluctuation,  and  con- 
taining viscid  matter  of  the  aspect  and  consistence  of  honey. 
Seated  always  in  the  skin  or  its  attached  surface,  meliceris  consists 
in  the  enlargement  of  one  of  the  subcutaneous  glands  or  follicles, 
arising  from  obstruction  of  its  excretory  duct.  The  mechanism  of 
its  formation  from  this  source  was  understood  by  PlenckJ  and 
Monteggia,§  and  was,  in  1819,  brought  under  notice  by  Sir  Astley 

* Morbid  Anatomy  of  the  Human  Brain,  p.  27. 

•t  Morbid  Anatomy  of  the  Brain,  p.  56. 

Josephi  Jacobi  Plenck,  NoTOin  Systema,  Classis  vii. 

§ “ Alcuni  cisti  si  formano  per  la  chiusura  del  orificio  escretore  dei  follicoli  sebacei 
e mucosi.”  Instituzioni  Chirurgiche  di  G.  B.  Monteggia,  edizione  seconda.  Milano, 
1613.  Vol.  II.  capo  xiii. 


SYSTEM  OF  EXHALANTS. 


201 


Cooper.*  It  must  not  be  forgotten,  however,  that  it  is  to  this  va- 
riety only  of  encysted  tumour,  that  this  mode  of  explanation  is  ap- 
plicable. Meliceris  is  in  short  the  only  example  of  the  folliculated 
tumour. 

Meliceris  may  occur  in  any  part  of  the  person  where  sebaceous 
follicles  exist.  When  on  the  scalp,  they  are  distinguished  among 
the  older  surgeons  by  peculiar  epithets  (talpa  et  testudo ;)  and 
natta  when  on  the  face.  In  such  situations  they  often  contain  hair. 
Those  which  Severinus  mentions  at  the  wrist  appear  to  have  been 
panglia  I a mistake  which  enables  us  to  understand  why  he  doubted 
whether  the  meliceris  was  an  encysted  tumour. 

Atheroma.  A wen  or  cyst,  indolent,  uniform  on  the  surface, 
firmer  than  the  meliceris.,  of  the  same  colour  with  the  skin,  and 
containing  granular  semifluid  matter  like  boiled  meat  or  saw-dust. 
It  is  always  confined  to  the  cellular  tissue.  The  mechanism  of  its 
formation  is  unknown,  unless  that  proposed  by  Monteggia  he  ad- 
mitted. According  to  this  pathologist,  the  tumour  may  originate 
in  slight  adhesive  inflammation  of  any  definite  portion  of  cellular 
tissue,  in  consequence  of  which  one  cell,  being  obstructed  and  pre- 
vented from  communicating  with  others,  is  progressively  distended 
by  deposition  of  matter,  which,  pressing  on  the  surrounding  tissue, 
gradually  condenses  it  into  a membrane  as  it  extends.  To  this 
idea  objections  have  been  already  stated  from  Bichat ; and  it  must 
be  admitted  that  facts  are  still  wanting  to  explain  this  otherwise 
than  by  saying,  that  the  cyst  is  formed,  and  secretes  its  proper 
contents. 

<^.  Steatoma.  A wen  or  cyst,  containing  adipose  matter  like  lard, 
or  fat  void  of  its  natural  yellow  colour,  and  become  white,  firm, 
and  granular  like  suet,  (Boyer,)  with  more  or  less  albumen,  ap- 
proaching to  the  nature  of  adipocu’e.  In  the  first  case  it  is  soft, 
compressible,  and  generally  small,  and  is  not  unfrequent  in  the 
eyelids  and  on  the  scalp.  In  the  second  case  it  is  more  common 
on  other  parts  of  the  body ; and  the  size  which  it  then  attains  is 
enormous.  In  all  surgical  works  almost  instances  are  given  of  the 
extraordinary  size  of  steatomatous  tumours.|  In  some  instances 

* Surgical  Essays,  by  Astley  Cooper,  F.  R.  S.,  and  Benjamin  Travers,  F.  R.  S. 
Part  II.  London,  1819.  Essay  iii.  On  Encysted  Tumom-s,  p.  220. 

f Vide  Joannes  Philip.  Ingrassias  de  Tumoribus.  Severini,  de  Abscessum  Natiu-a 
Recondita,  Lib.  iii.  Cap.  xxii.  Gulielmi  Fabricii  Hildani,  Opera  omnia.  Francof, 
1646.  Gabrielis  FalIo2m.  Op.  Lib.  de  Tumoribus,  p.  n.  c.  24.  Fabricii  ab  Aquapen- 
dente.  Lib.  i.  Ambrose  Pare,  Book  vi.  c.  xix.  one  of  twenty-six  pounds.  J.  Langius  ; 


202 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


osseous  matter  is  deposited  either  in  the  cyst,  or  with  the  sebaceous 
matter ; a circumstance  which  has  procured  it  from  Plenck  a se- 
parate place  with  the  title  of  osteosteatoma*  (Scheuzer,  Hund- 
termarc,  and  Haller.)  It  is  merely  a variety  of  the  steatom.  The 
appearance  of  steatomatous  cysts  in  bones  and  bony  tumours,  as 
seen  by  Kulm  and  Weidmann,|  belongs  to  another  place. 

Tj.  Lipoma.  This  name  was  first  applied  by  Littre  to  a wen  or 
cyst  filled  with  soft  matter  possessing  the  usual  properties  of  ani- 
mal fat.§  The  matter  of  steatom,  according  to  this  surgeon,  is 
either  not,  or  imperfectly  inflammable,  by  reason  of  its  degenera- 
tion or  commixture  with  some  other  animal  secretion.  The  pro- 
priety of  this  distinction  has  been  denied  by  Louis  and  others,  who 
maintain  that  these  tumours  differ  in  nothing,  unless  perhaps  in 
degree.  It  has  been  favoured,  nevertheless,  by  Morgagni,  and 
adopted  by  Plenck,  Desault,  Bichat,  and  various  foreign  surgeons, 
and  is  defended  by  Boyer,  who  represents  the  steatom  as  differing 
from  lipoma,  in  the  matter  being  white,  firm,  and  changed  from 
its  original  character,  and  in  possessing  the  tendency  to  degenerate 
into  cancer.;};  Plenck  had  previously  distinguished  the  lipoma,  by 
being  destitute  of  cyst,  a circumstance  not  required  by  Littre. 

Though  thus  admitted  to  differ,  the  anatomical  character,  as 
given  by  Morgagni,  ||  and  confirmed  by  Boyer,  is  in  both  nearly 
the  same.  A cyst  containing  unchanged  fat,  or  granular  adipose 
matter,  in  cells  formed  by  the  original  fibres  of  the  adipose  mem- 
brane, according  to  Morgagni,  or  those  of  the  filamentous  tissue, 
according  to  Boyer.  At  the  base  or  stalk  in  the  case  of  pendulous 
steatoms,  the  cells  are  compressed,  but  loose  in  the  body  of  the 
tumour. 

— one  said  to  weigh  sixty  pounds.  Papers  in  Haller’s  Disputationes  Chirurgicae,  Vol. 
V.  by  Elsholz,  Kell,  and  Friesse.  Fred.  Ruysch,  Epist.  ad  Boerhaave.  J.  Palfyn. 
Anatomie  du  Corps  Humain,  B.  ii.  chap.  ii.  Two  of  great  weight,  one  by  Schroeck, 
from  Morgagni  in  the  Ephem.  Nat.  Curios.  Cent.  5.  Ob.  27,  and  others  in  the  same 
work.  In  the  Phil.  Transactions,  Memoires  de  I’Academie  Royale  de  Chiiairgie,  &c. 
Edinburgh  Medical  Essays,  Vol.  III.  Medical  Com.  I.  190.  Ed.  Aled.  and  Surg. 
Journal,  Vol.  IX.  J.  P.  Weidmann  de  Steatomatibus,  4to,  Moguntise,  1817. 

* Breslau  Sammlungen,  1722,  p.  319.  Tittmani  Dissert.  Osteo-steatomatis,  cas.  rar. 
Ilalleri  Opuscula  Pathologica,  Obs.  6. 

t Joan.  Adami  Kulm,  Disputatio  Medico-Chirurgica  de  Exostosi  Steatomatode, 
&c.  Haller,  Vol.  V.  p.  653.  Weidmann,  p.  6,  and  Fig.  5. 

J Histoire  de  I’Academie  Royale  des  Sciences,  Anno  1709.  Observat.  Anatom.  3. 

§ Traite  des  Maladies  Chirurgicales,  Tome  II.  Chap.  i.  Art.  12. 

II  De  Sedibus  et  Causis  Alorborum,  Lib.  ix.  Epist.  I.  Art.  24  and  25,  and  Lib.  v. 
Epist.  Ixviii.  Art.  6 and  8. 


SYSTEM  OF  EXHALANTS. 


203 


This  description,  with  the  alleged  cancerous  tendency,  accords 
more  with  the  characters  of  the  adipose  sarcoma  than  those  of  the 
genuine  wen.  Personal  examination  enables  me  to  say,  that,  in 
the  ease  of  small  steatoms  of  the  scalp,  eyelids,  face,  &c.  no  fibres 
of  this  kind  are  recognised;  and  to  such  if  any  distinction  be 
adopted,  the  name  of  lipoma  should  be  confined.  In  the  case  of 
such  large  steatoms  as  I have  seen  in  other  regions  of  the  body, 
though  the  contents  are  firmly  connected  together,  and  some  fila- 
mentous threads  may  be  seen  here  and  there,  or  the  tumour  may 
be  even  separable  into  masses,  I have  not  been  able  to  trace  the 
distinct  arrangement  of  cells  mentioned  by  Morgagni  and  Boyer. 
Wiedmann  mentions,  that  in  one  case  the  matter  of  steatom  was  a 
sort  of  liquefied  fat,  and  in  another  firm  and  dense,  and  not  divid- 
ed into  lobes  or  cells. 

The  chemical  history  of  steatomatous  and  lipomatous  tumours 
is  imperfectly  known.  Many  years  ago  Dr  Bostock  analysed  a 
stearoid  tumour  without  obtaining  any  precise  result.  The  effects 
of  the  agents  employed  indicated  the  presence  of  neither  fat,  jelly, 
nor  adipocire  ; nor  was  any  change  accomplished  by  potass.  From 
its  general  intractability,  however,  and  the  effects  produced  by 
sulphuric  acid,  he  infers  that  it  is  composed  chiefly  of  carbonaceous 
matter.* 

I attempted  some  years  ago  to  examine  the  chemical  nature  of 
the  matter  contained  in  a steatomatous  cyst  removed  from  the  eye- 
lids. This  matter  was  of  a lemon  yellow  colour,  not  absolutely 
opaque,  yet  not  translucent,  and  like  a mixture  of  fat  and  wax. 
It  communicated  a stain  to  paper,  and  liquefied  on  exposure  to 
heat.  Though  it  was  perfectly  soluble  in  oil  of  turpentine,  I found 
that  no  method  which  I could  devise  could  make  it  unite  with  po- 
tassa.  It  was  also  soluble  in  ether.  From  the  experiments  of 
Chevreul,  it  is  not  improbable  that  they  contain  stearine,  cetine, 
or  adipocire.  But  it  must  be  admitted,  that  precise  information  is 
still  wanting. 

&.  Lupia.  This  term,  which  has  been  often  applied  generally  to 
wens,  {loupes,)  is  used  in  a more  limited  sense  by  Plenck,  to  desig- 
nate a cyst  containing  a spongy  substance  in  the  cellular  tissue,  of 
which  it  is  conceived  to  be  a degenerate  form.  It  is  convenient 
as  a head  to  which  certain  rare  and  anomalous  cystic  tumours  may 
be  referred. 

* Edin.  Mecl.  Journal,  Vol.  II.  p.  14  and  17. 


204 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


I.  Melanoma.  In  many  instances  the  melanotic  matter,  already 
mentioned,  is  deposited  in  a cyst.  In  such  circumstances,  there- 
fore, it  is  referable  to  this  head. 


CHAPTER  X. 

LYMPHATIC  SYSTEM,  Vasa  Lymphatica, — Vasa  Lymphifera, — 
Lijmphce-Ductus  of  glisson  and  jolyffe. — systems  absor- 
BANT.  Die  Saugadern. 


Section  I. 

In  most  situations  of  the  human  body,  and  especially  in  the  vi- 
cinity of  arterial  and  venous  trunks,  there  are  found  long,  slender, 
hollow  tubes,  pellucid  or  reddish,  which  present  numerous  knots, 
joints,  or  swellings  in  their  course,  and  to  which  the  name  of  lym- 
phatics or  absorbents  has  been  given.  It  is  most  expedient  to  em- 
ploy the  former  appellation  only,  as  the  latter  implies  the  perform- 
ance of  a function,  the  reality  of  which  has  been  much  questioned 
of  late  years. 

Though  Eustachius  had  seen  the  thoracic  duct  in  the  horse,  and 
some  slight  traces  of  a knowledge  of  vascular  tubes,  different  either 
from  arteries  or  veins,  are  found  in  the  writings  of  Nicolaus  Massa, 
Falloppius,  and  Veslingius,  the  merit  of  establishing  their  existence 
is  generally  ascribed  to  Caspar  Asellius,  a physician  of  Pavia. 
This  anatomist,  who  had,  in  1622,  seen  the  white-coloured  tubes, 
then  first  named  lacteals.  issuing  from  the  intestines  of  the  dog, 
observed  also  a cluster  of  vessels  less  opaque  near  the  portal  emi- 
nences of  the  liver, — an  observation  which  he  afterwards  repeated 
in  the  horse  and  other  quadrupeds.  The  same  vessels  were  also 
described  and  delineated  by  Highmore. 

Passing  over  the  uncertain  and  obscure  hints  given  by  Walaeus 
and  Van  Horne,  the  first  exact  information  after  Asellius  is  that 
which  relates  to  Olaus  Rudbeck,  who,  in  1650,  is  said  to  have  seen 
them  in  a calf,  and  to  have  demonstrated  the  thoracic  duct,  and  the 
dilated  sac,  afterwards  termed  receptaculum  ckyli. 

i 


LY3IPHATIC  SYSTEM,  &C. 


205 


Glisson  informs  us  that  JolyfFe  had,  in  1652,  imparted  to  him 
the  knowledge  of  a set  of  vessels  diflFerent  from  arteries  and  veins ; 
and  it  appears  from  the  testimony  of  Wharton,  that  JolyfFe  had  de- 
monstrated these  vessels  in  1650.* * * §  In  short,  the  discovery  of  lym- 
phatics, and  the  correction  of  some  errors  of  Asellius,  is  ascribed 
to  the  English  anatomist,  not  only  hy  Wharton  and  Glisson,  hut 
by  Charleton,  Plott,  Wotton,  and  Boyle. 

The  existence  of  these  vessels,  thus  partially  demonstrated,  was 
afterwards  more  fully  established  by  the  researches  of  Bartholin, 
Pecquet,  Bilsius,  Nuck,  the  second  Monro  and  Haller.  It  is 
chiefly  to  the  exertions  of  William  Hunter  and  his  pupils,  Hew- 
son,|  Sheldon, J and  Cruikshank§  in  this  country,  and  to  those  of 
Mascagni II  in  Italy,  that  the  anatomical  world  are  indebted  for  the- 
complete  examination  and  history  of  this  system  of  vessels. 

The  lymphatic  vessels  consist,  in  the  members,  of  two  layers,  a 
superficial  and  a deep-seated  one.  The  first  is  situate  in  the  sub- 
cutaneous cellular  tissue,  between  the  skin  and  the  aponeurotic 
sheaths,  and  accompanies  the  subcutaneous  veins,  or  creeps  in  the 
intervals  between  them.  A successful  injection  of  these  superficial 
lymphatics  will  show  an  extensive  network  of  mercurial  tubes  sur- 
rounding the  whole  limb. 

The  deep-seated  layer  of  lymphatics  is  found  chiefly  in  the  in- 
terspaces between  the  muscles,  and  along  the  course  of  the  arterial 
and  venous  trunks.  In  tracing  both  layers  of  lymphatics  to  the 
upper,  fixed,  or  attached  end  of  the  members,  we  find  they  increase 
in  volume,  and  diminish  in  number.  At  the  connection  of  the 
members  with  the  trunk,  they  are  observed  to  pass  through  certain 
spheroidal  or  spherical  bodies,  termed  lymphatic  glands  or  gangli- 
ons. The  lymphatics  of  the  upper  extremity,  after  passing  through 
the  glands  of  the  arm-pit,  terminate  in  trunks,  which  open  into  the 
subclavio-jugular  veins,  one  on  each  side  of  the  neck.  Those  of 

* Francisci  Glissonii  Anatomia  Hepatis,  Cap.  xxxi.  Thomse  MTiarton,  Adenographia, 
Cap.  ii.  p.  98. 

+ Experimental  Inquiries,  Part  the  Second.  By  ‘William  Hewson,  F.  R.  S.  Lon- 
don, 1774,  8vo.  Also  the  Works  of  William  Hewson,  F.  R.  S.  Edited  by  George 
Gulliver,  F.  R.  S.  By  Sydenham  Society'.  London,  1846. 

J The  History  of  the  Absorbent  System,  &c.  by  John  Sheldon,  Surgeon,  F.R.S.,  &c. 
London,  1784.  Folio. 

§ The  Anatomy  of  the  Absorbing  'Vessels  of  the  Human  Body.  By  William  Cruik- 
shank,  London,  1786,  4to.  The  Second  Edition,  London,  1790. 

II  Pauli  Mascagni  Vasomm  Ly  mphaticorum  Corporis  Humani  Historia  et  Ichno- 
graphia,  foUo,  Paris,  1787.  See  also  Prodrome,  &c.  Capitolo,  i. 


206 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  lower  extremity,  after  passing  through  the  glands  of  the  groin, 
proceed  with  the  common  iliac  vein  into  the  abdomen,  where  they 
unite  with  other  lymphatics. 

The  lymphatics  of  the  trunk  consist  in  like  manner  of  two  layers, 
a subcutaneous  and  deeper  seated  one,  distributed  in  the  chest  be- 
tween the  muscles  and  pleura,  and  in  the  abdomen  between  the 
muscles  and  peritoneum.  In  the  chest  and  belly,  each  organ  pos- 
sesses a superficial  layer  of  lymphatics  distributed  over  its  surface, 
and  pertaining  to  its  membranous  envelope ; the  other  ramifying 
through  its  substance,  and  pertaining  to  the  peculiar  tissue  of  the 
organ.  This  twofold  arrangement  is  most  easily  seen  in  the  lungs, 
the  heart,  the  liver,  spleen,  and  kidneys. 

In  a similar  manner  are  arranged  the  lymphatics  in  the  exter- 
nal parts  of  the  scull,  on  the  face,  where  they  are  very  numerous, 
in  the  spaces  between  the  muscles,  and  on  the  neck,  in  which  they 
pass  through  numerous  glands.  No  lymphatics,  however,  have 
been  found  in  the  brain,  the  spinal  chord,  their  membranous  en- 
velopes, the  eye,  or  the  ear. 

All  the  lymphatics  hitherto  known  terminate  in  two  principal 
trunks.  One  of  these,  termed  from  its  site  thoracic  duct,  {Ductus 
thoracicus ; die  Milch-brustrbhre  ; ie  canal  thoracique)  is  situate  on 
the  left  side  of  the  dorsal  vertebrm.  It  receives  the  lymphatics  of 
the  lower  extremities,  of  the  belly,  and  the  parts  contained  in  it ; 
those  of  great  part  of  the  chest,  and  those  of  the  left  side  of  the 
head,  neck,  and  trunk,  and  left  upper  extremity.  The  other  lym- 
phatic trunk,  which  is  situate  on  the  right  side  of  the  upper  dorsal 
vertebrae,  is  formed  by  the  union  of  the  lymphatics  of  the  right  side 
of  the  head,  neck,  right  upper  extremity,  and  some  of  those  of  the 
chest.  Both  of  these  trunks,  it  is  well  known,  open  into  the  sub- 
clavio-jugular  vein  of  each  side. 

That  lymphatics  terminate  in  branches  of  the  venous  system  has 
been  asserted  on  the  authority  of  various  observers.  Steno,  for 
instance,  states  that  he  traced  the  lymphatics  from  the  right  side  of 
the  head,  the  chest,  and  pectoral  extremity  in  animals  into  the  right 
axillary  vein  ; and  he  gives  delineations  of  anastomotic  connections 
of  several  lymphatics  with  the  axillary  and  jugular  veins.  Similar 
facts  have  been  reported  by  Nuck,  Richard  Hale,  Bartholin,  and 
Hartmann.  Ruysch  traced  the  lymphatics  of  the  lung  into  the 
subclavian  and  axillary  veins ; Hrelincourt  those  of  the  thymus 
gland  in  animals  into  the  subclavians ; and  Hebenstreit  saw  those 
of  the  loins  pass  into  the  vena  azygos. 


LYMPHATIC  SYSTEM,  8cC. 


207 


Haller,  though  unwilling  to  deny  the  testimony  of  these  ob- 
servers, regards  it  liable  to  various  sources  of  fallacy,  and  doubts 
the  direct  communication  of  the  lymphatic  and  venous  systems.  John 
F.  Meckel,  the  grandfather,  maintained  in  1771  the  communication, 
from  the  circumstance,  that  he  injected  the  lymphatics  from  the 
veins.*  Hewson,  though  not  doubting  the  fact,  regards  it  as  an 
exception  to  the  general  rule.  Cruikshank,  again,  states  that  he 
never  saw  a lymphatic  vessel  inserted  into  any  other  red  veins  than 
the  subclavians  and  jugulars.  The  termination  remarked  by  Steno 
and  his  successors  constitutes  in  truth  the  common  trunk  or  lympha- 
tic vein  admitted  by  Cruikshank, — a thoracic  duct  of  the  right  side. 

This  mode  of  termination  was  afterwards  in  1821  revived  by 
Tiedemann  and  Fohman,-f*  who,  in  the  seal,  state  that  the  lactiferous 
vessels  communicate  with  veins  arising  from  the  mesenteric  glands, 
and  pass  thence  into  the  venous  trunks  without  proceeding  through 
the  thoracic  duct.  This,  however,  was  shown  by  Dr  Knox  to  be 
a mistake,  resulting  from  the  decomposed  state  of  the  animals 
examined  by  the  German  anatomists.  J M.  Lauth  J unior  of  Stras- 
bourg, again,  conceives  that  he  has  demonstrated,  that  lymphatics 
communicate  with  veins  within  the  substance  of  organs,  and  in 
the  interior  of  the  lymphatic  glands  ;§  an  inference  which  at  pre- 
sent requires  further  verification.  The  statements  of  Lippi  of 
Florence,  that  every  lymphatic  almost  communicates  freely  with 
venous  tubes,  is  still  more  improbable,  and  has  been  rendered  ex- 
ceedingly doubtful  by  the  researches  of  Rossi  ;||  and  Panizza  shows 
that  there  is  no  communication  between  the  minute  arteries  and  the 
lymphatics. 

The  connections  of  the  ends  of  lymphatics  with  the  organs  and 
tissues  from  which  they  arise,  termed  their  origins^  are  completely 
unknown.  In  some  favourable  instances  the  lymphatics  of  the  in- 
testinal canal  are  so  filled  with  a reddish  or  whitish  fluid  after  the 
process  of  digestion  has  continued  for  some  time,  that  not  only  are 
their  larger  branches  easily  seen,  but  by  the  aid  of  the  miscroscope 

* Jo.  Fr.  Meckel,  Nova  Experimenta  et  Observationes  de  finibus  Venarum  ac  Va- 
sorum  lymphaticorum,  &c.  § I.  p.  4.  Lugduni  Bat.  1772.  8vo. 

-j-  Anatomische  Untersucbungen  uber  die  Verbinduug  der  Saugadern  mit  den  Venen. 
Heidelberg,  1821. 

J On  the  Anatomy  of  the  Lacteal  System  in  the  Seal.  Edin.  Med.  and  Surgical 
Journal,  Vol.  XXII.  p.  26,  &c. 

§ Essai  sur  les  Vaisseaux  Lymphatiques.  Strasbourg,  1824. 

II  Cenni  sulla  comunicazione  dei  vasi  linfatici  colle  vene  ; di  Giovanni  Rossi  Doc- 
tore,  &c.  Annali  UniversaLi  di  Medecina,  Anno  1826.  Vol.  XXXVII.  p.  52. 


208 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


some  of  the  smaller  may  be  traced  to  their  commencement.  This, 
which  was  ascertained  by  Cruikshank,  (p.  55  and  58,)  and  con- 
firmed by  Hewson, ' Bleuland,  and  Hedwig,  has  been  contradicted 
by  the  observations  of  Rudolphi  and  Albert  Meckel.  In  all  other 
parts,  however,  though  a successful  injection  may  show  the  course 
and  distribution  of  many  of  the  smallest  lymphatics,  yet  no  orifices 
are  perceptible  at  the  point  at  which  they  seem  to  stop,  and  we  are 
uncertain  whether  these  points  are  their  origins.  (Cruikshank.) 
Mere  observation  is  here  as  unavailing  as  in  regard  to  the  termi- 
nation of  exhalants.  The  continuation  of  lymphatics  with  arteries, 
unless  in  the  case  of  those  which  arise  from  the  interior  of  arterial 
tubes,  (Lauth,)  is  not  satisfactorily  established.  It  has  been  con- 
jectured, however,  that  their  ends  or  imperceptible  origins  are  con- 
nected to  the  tissues  to  which  they  are  traced,  and  that  the  lym- 
phatics arise  in  this  manner  from  these  tissues. 

The  lymphatics  are  distinguished  by  being  in  general  cylindri- 
cal in  figure,  and  by  varying  in  calibre  at  short  spaces.  In  this 
respect  they  differ  from  the  arteries  and  veins.  It  has  been  further 
justly  remarked  by  Gordon,  that  the  middle-sized  lymphatics  are 
remarkably  distinguished  from  the  corresponding  parts  of  the  ar- 
terial and  venous  system  by  three  peculiarities.  When  two 
lymphatics  unite  to  form  a third,  the  trunk  thus  formed  is  seldom 
or  never  larger  than  either  of  them  separately ; 2rf,  their  anasto- 
moses with  each  other  are  continual ; and,  3J,  they  seldom  go  a 
great  space  without  first  dividing  into  branches,  and  then  reuniting 
into  trunks.* 

The  outer  surface  of  a lymphatic  is  filamentous  and  rough,  the 
inner  smooth  and  polished,  like  that  of  small  veins.  It  is  impossi- 
ble to  observe  the  structure  of  these  tubes  in  the  middle-sized,  or 
even  in  the  large  lymphatics ; and  anatomists  have  generally  been 
satisfied  with  supposing  that  the  structure  of  all  of  them  is  similar 
to  that  of  the  thoracic  duct,  or  some  other  large  vessels  equally 
susceptible  of  examination.  According  to  the  observations  of 
Cruikshank,  (Chap,  xii.)  which  have  been  verified  by  Bichat,  the 
thoracic  duct  presents,  a layer  of  dense  firm  filamentous  or 
cellular  tissue,  exactly  similar  to  that  found  inclosing  arterial  and 
venous  tubes,  which  the  latter  regards  as  foreign  to  the  vessel,  but 
giving  it  a great  degree  of  support  and  protection  ; 2d,  a proper 
membrane,  delicate,  transparent,  and  moistened  inside  by  an  unctu- 

* System,  p.  71. 


LYMPHATIC  SYSTEM,  &C. 


209 


ous  fluid,  which  he  seems  inclined  to  ascribe  to  transudation.  Mus- 
cular fibres,  of  which  Sheldon  speaks  positively,  Cruikshank  re- 
presents, though  seen  in  some  instances,  (Chap,  xii.)  yet  to  be  more 
generally  not  demonstrable.  Their  existence,  though  admitted  by 
Schreger  and  Soemmering,  is  denied  by  Mascagni,  Rudolphi, 
and  J.  F.  Meckel,  and  I,  may  add,  by  Bichat  and  Bedard.  This 
account  difibrs  not  much  from  that  of  Dr  Gordon,  who  could  not 
recognize  distinctly  more  than  one  coat,  similar  to  the  inner  coat 
of  veins.  The  filamentous  layer  noticed  by  Bichat,  and  considered 
by  Mascagni  as  an  external  coat,  is  of  course  excluded. 

The  knotted  or  jointed  appearance  of  lymphatics  is  occasioned 
chiefly  by  short  membranous  folds  in  their  cavity  called  valves. 
These  folds  are  thinner  than  the  venous  valves;  but  they  are 
equally  strong,  and  have  the  same  shape  and  mode  of  attachment 
to  the  inside  of  the  vessel.  They  are  generally  found  in  pairs,  but 
never  three  at  the  same  point.  A single  valve  is  sometimes  found 
at  the  junction  of  a large  branch  with  a trunk,  or  of  a trunk  with 
a vein.  According  to  Cruikshank  there  is  considerable  variety  in 
the  distribution  of  valves;  but  in  general  a pair  of  valves  will  be 
found  at  every  one-twentieth  of  an  inch  in  lymphatics  of  middling 
size.  In  the  larger  lymphatics  they  are  less  numerous  than  in  the 
small.  The  structure  of  these  valvular  folds  is  as  little  known  as 
that  of  the  inner  membrane,  of  which  they  appear  to  be  prolonga- 
tions. According  to  Mascagni  they  sometimes  contain  a small 
portion  of  fine  adipose  substance. 

The  tissue  which  forms  the  lymphatic  tubes  is  strong,  dense, 
and  resisting ; and,  from  the  weight  of  mercury  which  they  bear 
without  rupture,  it  has  been  generally  concluded,  that  they  are 
stronger  in  proportion  to  their  size  than  veins.  This  tissue  also 
possesses  considerable  elasticity. 

The  opposite  states  of  lymphatics  dm'ing  digestion  and  after  long 
fasting,  and  the  phenomena  of  mercurial  injections,  prove  that  the 
tissue  of  which  they  consist  is  distensible  and  contractile.  Though 
it  does  not  exhibit  appearances  of  muscular  structure,  it  has  been 
long  supposed  to  be  endowed  with  a property  analogous  to  irrita- 
bility. Such  is  the  inference  which  Hunter,  Hewson,  Cruik- 
shank, and  others  have  derived  from  various  phenomena  in  the 
living  and  recently  dead  tissue. 

Though  Bichat  doubted  svhat  he  termed  organic  sensible  con- 
tractility, yet  he  admitted  the  insensible  contractility  as  necessary 
to  the  functions  ascribed  to  lymphatics.  Previous  to  his  time 

o 


210 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Sclireger,  in  different  experiments,  observed  the  first  of  these  qua- 
lities in  consequence  of  the  application  not  only  of  acids,  butter  of 
antimony,  and  alcohol,  but  even  of  hot  water  and  cold  air.  Simi- 
lar contractions  and  relaxations  have  been  induced  by  mechanical 
irritation.*  Such  phenomena  are  observed  not  only  during  life, 
but  even  after  death  ; and  if  we  add  to  this,  that  the  thoracic  duct 
is  often  after  death  large  and  flaccid,  though  empty,  but  in  the  liv- 
ing body  is  almost  always  contracted  and  scarcely  visible,  and  that 
a portion  of  it  included  between  two  ligatures  and  punctured, 
quickly  expels  its  contents,  it  may  be  inferred,  according  to  Tiede- 
mann  and  Bedard,  that  the  lymphatic  tissue  possesses  a considerable 
degree  of  this  vital  or  organic  property. 

Section  II. 

The  lymphatic  vessels  have  been  supposed  to  perform  an  import- 
ant part  in  the  formation  of  the  diseases  incident  to  the  animal 
body.  In  addition  to  the  ordinary  causes  of  disease  which  affect 
all  organic  substances,  the  several  derangements  of  property  or 
function  to  which  they  are  liable  have  been  supposed  to  exert  a 
powerful  influence  on  other  tissues  and  organs,  and  on  their  func- 
tions. On  this  principle  Hewson,  Cruikshank,  Thomas  White, 
Nudow,  Isenflamm,  Johnstone,  and  Maanen,  have  ascribed  to  dif- 
ferent forms  and  degrees  of  disorder  of  the  lymphatic  system  a very 
large  proportion  of  the  diseases  incident  to  the  human  body.  All 
of  these  authors,  nevertheless,  have  been  exceeded  by  Soemmering, 
and  more  recently  by  Alard,  both  of  whom  represent  the  lym- 
phatics as  mainly  concerned  in  every  morbid  state  of  tbe  human 
body.  The  former  has  delineated  an  extensive  picture  of  diseases, 
in  the  production  of  which  the  lymphatics  are  believed  to  be  more 
or  less  concerned.  Besides  immediate  morbid  states  of  the  lym- 
phatics themselves,  he  enumerates  upwards  of  sixty  diseases  and 
morbid  states  of  the  human  body,  in  which,  according  to  one  or 
another  pathologist,  the  lymphatics  have  an  influence,  direct  or 
indirect,  immediate  or  remote.f  The  latter  reasons  most  strenu- 
ously for  the  universal  influence  of  the  lymphatic  system  in  every 
disease  almost  of  the  animal  frame. 

* Schreger  de  Irritabilitate  Vas.  Lymph.  Lips.  1789. 

t S.  Thomas  Soemmering  de  Morbis  Vasorum  Absorbentium  Corporis  Humani  sive 
Dissertationis  quae  prcemium  retulit  Societatis  Rheno-Trajectinae,  anno  1794,  Pars 
Pathologica.  Trajecti  ad  Moenum,  1795.  8vo. 


LYMPHATIC  SYSTEM,  &C. 


211 


Little  doubt  can  be  entertained,  that  by  these  authors  the  in- 
fluence of  the  lymphatic  vessels  has  been  very  much  overrated. 
Notwithstanding  the  authority  of  their  names,  it  is  certain  that 
neither  anatomical  inspection,  nor  the  observation  of  the  pheno- 
mena and  efiects  of  disease,  justify  the  views  advanced  by  these 
authors.  It  further  requires  little  argument  to  show,  that  this 
mode  of  explaining  the  formation  and  nature  of  diseases  does  not 
tend  to  the  advancement  of  accurate  pathological  knowledge. 

All  the  diseases  to  be  referred  to  this  head  come  naturally  under 
two  divisions.  The  first  consists  of  disordered  states  occurring  in 
the  lymphatic  vessels  themselves.  In  the  second  are  included  mor- 
bid states  of  other  textures  or  systems,  arising  immediately  from, 
disease  of  the  lymphatics. 

1.  Inflammation^  — i^Angioleucitis.')  The  first  morbid  state  to 
be  mentioned  as  incident  to  the  lymphatics  is  inflammation.  As  a 
spontaneous  occurrence  it  is  little  known,  and  perhaps  is  exceed- 
ingly rare.  Hendy,  indeed,  undertook  to  show,  that  inflammation 
of  the  lymphatics  was  the  pathological  cause  of  Barbadoes  leg  ;* 
and  this  view,  wLich  has  been  almost  implicitly  adopted  by  every 
subsequent  observer,  has  been  strenuously  maintained  and  illus- 
trated by  M.  Alard.f  I have  already  adduced  such  facts  and  ar- 
guments as  I conceive  are  sufficient  to  show  that  this  disease  de- 
pends on  a peculiar  inflammation  of  the  filamentous  tissue  of  the 
limb,  recurring  periodically,  and  terminating  in  albuminous  exu- 
dation ; and  that  the  affection  of  the  lymphatic  glands,  vessels,  &c. 
on  which  the  hypothesis  of  Dr  Hendy  is  founded,  is  an  effect  of  this 
diseased  state.  It  is  unnecessary,  therefore,  to  give  the  subject 
more  consideration. 

Not  less  objectionable  is  tbe  notion  advanced  by  Charles  White, $ 
that  inflammation  or  obstruction  of  the  lymphatics  is  the  cause  of 
the  swelled  leg,  (j)hlegmasia  dolensf)  of  puerperal  women.  Obser- 
vation and  dissection  concur'in  showing  that  this  malady  arises  from 
inflammation  of  the  uterine  and  pelvic  veins  terminating  in  albu- 
minous or  sero-albuminous  exudation,  and  causing  obstruction  to 
the  venous  circulation. 

Angioleucitis  Uterina  puerperarum.  Inflammation  has  been 

■*  Treatise  on  the  Glandular  Disease  of  Barbadoes,  proving  it  to  be  seated  in  the 
Lymphatic  System.  By  John  Hendy.  London,  1784. 

-f-  Histoire  d’une  Maladie  particuliere  an  Systeme  Lymphatique,  &c.  1806  ; et 
Nouvelles  Observations  sur  I’Elephantiasis  des  Arabes.  Par  M.  Alard,  1811. 

X Inquiry  into  the  Nature  and  Cause  of  that  Swelling  in  one  or  both  of  the  Lower 
Extremities  in  Lying-jn- Women.  By  Charles  White,  Surgeon.  Warrington,  1784. 


212 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


observed  to  attack  the  lymphatic  vessels  of  the  womb  in  puerperal 
fever,  and  then  it  too  often  proceeds  to  suppuration.  The  uterine 
lymphatics  are  then  seen  extending  over  the  surface  of  the  organ 
jointed  and  knotted,  and  distinctly  presenting  purulent  matter  in 
their  interior,  and  sometimes  along  their  exterior.  Tonelle  found 
among  222  fatal  cases  of  puerperal  fever,  that  in  32  purulent  mat- 
ter was  contained  in  the  lymphatics.*  This  shows  tliat  in  about 
one-seventh  of  the  cases  of  puerperal  fever,  inflammation  and  sup- 
puration of  the  lymphatics  may  take  place.  This  doctrine  has  been 
forcibly  illustrated  by  Cruveilhier.j 

Inflammation  of  lymphatic  vessels  may  almost  invariably  be  traced 
to  irritation,  or  an  irritating  cause  at  their  organic  extremities. 
Thus  a sore  in  the  finger  or  hand,  whitloe,  or  other  inflamed  states 
of  the  fingers,  are  often  attended  with  painful  red  streaks  or  lines, 
extending  up  the  arm  to  the  arm-pit.  These  red  streaks  indicate 
inflammation  of  the  subcutaneous  lymphatics.  In  like  manner  I 
have  seen  a blister  applied  to  the  surface  of  the  belly  cause  inflam- 
mation of  the  lymphatics  leading  to  the  inguinal  glands. 

The  inflammation  when  not  violent  terminates  in  resolution.  In 
more  severe  cases  it  may  cause  effusion  of  lymph  into  the  cavity  of 
the  vessel,  so  as  to  effect  adhesion  and  obliterate  its  canal.  This 
was  probably  the  cause  of  the  obstruction  which  Mascagni  states 
he  found  in  the  lymphatics  of  several  subjects  after  the  use  of  blis- 
ters. Suppuration,  as  a consequence  of  inflammation  of  lympha- 
tics, is  little  known. 

2.  Wounds  of  lymphatics  must  occur  frequently.  In  truth, 
scarcely  an  incision  dividing  the  skin  and  cellular  membrane  can 
fail  to  involve  several  lymphatics,  and  every  deep  incision  divides 
many  of  them,  j;  They  appear  to  unite  easily.  Is  the  cavity  obli- 
terated ? The  frequent  anastomoses  render  this  event  of  no  con- 
sequence. Hewson  observed  that  in  several  instances  lymphy  coa- 
gulable  fluid  continued  to  ooze  from  the  wounded  vessel  for  days. 

3.  Cirsus  (K/gffoj)  or  Varicose  Dilatation.  This  name  is  applied 
by  Meckel  to  denote  a dilated  state  of  lymphatics  similar  to  varix 
in  veins.  Schreger  and  Tilesius  delineate  what  they  conceive  to 
be  varix  in  the  lymphatics  of  the  conjunctiva  ; Mascagni  repre- 

* Des  Fievres  Puerperales  observees  a la  Maternite  de  Paris  pendant  I’annee  1829. 
Par  M.  Tonelld,  Archives  Generales,  XXII.  p.  345. 

T Anatomie  Pathologique. 

J Monro  in  Edin.  Medical  Essays,  Vol.  V.  Art.  xxvii. 


LYMPHATIC  SYSTEM,  &C. 


213 


sents  the  same  condition  in  those  of  the  lungs ; and  Soemmering 
describes  those  of  the  intestines  as  varicose  in  hernia.  The  same 
condition  was  observed  by  Bichat  in  the  lymphatics  of  serous  mem- 
branes. In  dropsical  subjects  they  are  always  much  distended 
with  fluid  ; and  hence  the  anatomist  finds  their  demonstration  much 
more  easy  in  such  circumstances. 

4.  Rupture  of  the  lymphatics  has  been  assumed  as  a probable 
cause  of  consumption  by  Morton,  of  scrofula  in  general  by  Acker- 
man, of  Barbadoes  leg  by  Hendy,  of  puerperal  swelled  leg  by 
White,  of  dropsy  by  Van  Swieten,  Haase,* * * §  Assalini,!  Metzler,j; 
and  Soemmering, § and  of  white  swelling  of  the  joints  by  Bram- 
billa.  II  Yet  in  neither  of  these  diseases  has  the  existence  of  rup- 
ture of  the  lymphatics  been  demonstrated ; nor  has  the  accident 
been  shown  to  be  one  of  ordinary  frequency.  Baillie  admits  that 
the  thoracic  duct  may  have  been  ruptured.  But  Guifiart  is  the 
only  person  who  is  said  to  have  seen  this  accident  in  the  person  of 
a boy  of  fourteen. IT 

5.  Dilatation  loitli  Obstruction.  Soemmering  repeatedly  found 
the  lacteals  of  the  small  intestines  near  the  duodenum  filled  and 
distended  with  a thick  curdy  matter  like  soft  cheese.  Of  the  same 
deposition  in  the  lacteals  of  the  jejunum  with  much  induration, 
Walter  delineates  an  example  in  a man  of  about  thirty.  Edward 
Sandifort  represents  the  lacteals  in  an  infant  of  a few  weeks  much 
thickened,  approaching  to  varicose,  with  swelled  mesenteric  glands.** 
And  Ludwig  saw  them  in  a similar  state  in  a girl  of  seven,  with 
induration  of  these  glands. 

6.  Osseous  Deposition.  Callous  hardness,  with  osseous  matter, 
was  seen  in  the  coats  of  the  lymphatics  in  the  pelvis  by  Mascagni, 
Cruikshank,  and  Walter  found  them  ossified,  and  of  stony  hard- 
ness. The  thoracic  duct  was  found  filled  with  caseous  or  tyroma- 
tous  matter  by  Poncy,  all  the  neighbouring  glands,  both  thoracic 
and  mesenteric,  being  enlar-ged  and  tyromatous  ;ft  and  with  earthy 

* J.  Gotti.  Haasius  de  Vasis  Cutis,  &c.  Absorbentibus.  Leip.  1786. 

t Essai  Medical  sur  les  Vaisse.aux  Lymphatiques,  &c.  p.  56. 

+ Dissertatio  de  Hydrope,  &c.  p.  23. 

§ De  Morbis  Vasomm  Absorbentium,  p.  132. 

II  Acta  Acad.  Medico-Chirurg.  Militaris  Viennensis,  Tome  I.  p.  16. 

^ Apiid  Barth olini  Opuscula  nova  de  vasis  Lymphaticis,  &c.  Hafiiise,  1670. 

**  Observation.  Anatom.  Pathologic.  Lib.  ii.  cap.  8. 

tt  Nouveau  Recueil  D’Observations  Chirurgicales  Faites  par  M.  Saviard.  A.  Maitve- 
Chirurgien  de  I’Hotel  Dieu  et  Jeure  a Paris.  Paris,  1702.  Obs.  CXI.  p.  500. 


214 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


or  osseous  matter  by  Assalini.*  Cheston  found  it  obstructed  with 
a solid  substance  resembling  calcareous  matter  ;f  Bayford  found  it 
much  obstructed  by  the  pressure  of  an  aneurismal  tumour  and 
Scherb  is  said  to  have  met  with  an  actual  concretion.§  All  these 
phenomena,  excepting  that  of  the  aneurismal  tumour,  are  the  ef- 
fects of  strumous  disorder. 

The  lymphatics  have  been  long  supposed  to  be  the  agents  con- 
cerned in  the  formation  of  king’s  evil,  (^struma,  scrofula^')  and  in 
the  development  of  the  disease  when  latent.  What  are  the  proofs 
of  this  opinion  ? Have  the  lymphatics  been  actually  found  disor- 
ganized in  cases  of  strumous  disease,  and  does  scrofula  never  take 
place  without  traces  of  this  disorganization  ? Do  they  act  as  the  cause, 
or  do  they  partake  in  the  effects  of  another  morbific  agent  more 
general  in  operation  ? In  answering  these  questions  much  will  de- 
pend upon  the  meaning  attached  to  the  term  scrofula.  If  this  be  a 
disease  appearing  in  the  lymphatic  glands  only,  there  may  be  some 
ground  for  the  opinion.  But  to  assemble  the  numerous  disorders 
termed  strumous,  under  the  head  of  the  lymphatics,  implies  conclu- 
sions which  are  not  supported  by  anatomical  facts. 

It  seems  more  natural  and  more  consistent  with  the  known  phe- 
nomena of  diseased  action,  to  place  the  genesis  of  struma,  whatever 
that  may  be,  in  the  process  of  digestion,  in  the  lacteal  vessels  that 
arise  from  the  jejunum^  and  in  the  blood  of  the  small  capillary 
vessels  generally.  From  what  is  most  generally  observed,  the  pro- 
cess of  arterialization  in  the  lungs  appears  to  be  defective. 

Since  the  arguments  which  have  been  adduced  against  the  ab- 
sorbent power  of  the  lymphatic  vessels  by  Mayer,  Magendie,  and 
others,  their  influence  either  in  the  production  of  dropsy,  or  in  re- 
moving it,  seems  to  be  very  doubtful. 

How  far  can  they  be  admitted  to  explain  the  process  of  ulcerative 
absorption  so  ingeniously  contrived  and  ably  maintained  by  J ohn  Hun- 
ter? and  what  share  can  they  be  supposed  to  possess  in  the  removal  of 
other  matters,  either  proper  or  foreign  to  the  system,  as  that  patholo- 
gist believed  ? Upon  these  questions  accurate  facts  are  still  wanting. 

* Essai  Medical  sur  les  Vaisseaux  Lymphatiques,  &c.  Par  Paolo  Assalini.  Tu- 
rin, 1787-8. 

+ Philosophical  Transactions,  Vol.  LXX.  1780.  And  Pathological  Inquiries  ; and 
Observations  on  Surgery,  from  the  Dissections  of  Morbid  Bodies  ; with  an  Appendix 
containing  three  Cases  on  different  subjects.  By  Richard  Browne  Cheston,  Surgeon 
to  the  Gloucester  Infirmary.  4to.  Gloucester,  1766. 

J Medical  Observations  and  Inquiries,  Vol.  III.  p.  18. 

§ Apud  Haller,  Dissertation.  Patholog. 


LYMPHATIC  GLAND  Oil  GANGLION. 


215 


CHAPTER  XL 

LYMPHATIC  GLAND  OR  GANGLION,  KERNEL. {GlandulcE  Lym 

phaticcB, — Glandulce  Conglobntai. — Die  Saugader-Dreusen.) 

Section  I. 

This  is  the  proper  place  to  consider  the  structure  of  those  bodies 
which  are  in  common  language  termed  kernels,  to  which  anatomists 
have  applied  the  name  of  lymphatic  glands,  and  the  French  ana- 
tomists have  more  recently  given  that  of  lymphatic  ganglions.  The 
general  appearance,  figure,  and  usual  situation  of  these  bodies,  are 
well  known  and  described  in  the  common  treatises  on  anatomy.  In 
general  they  are  spheroidal,  seldom  quite  globular,  and  most  com- 
monly their  shape  is  that  of  a flattened  spheroid.  In  different  sub- 
jects, and  in  subjects  at  different  ages,  they  vary  from  two  or  three 
lines  to  an  inch  in  diameter.  The  medium  rate  is  about  half  an 
inch.  Their  surface  is  smooth ; their  colour  grayish-pink,  some- 
times pale  red,  bluish,  or  of  a peach- blossom  tinge, — varieties  which 
seem  to  depend  on  degrees  of  bloody  transudation  ; for  when  wash- 
ed and  slightly  macerated,  they  assume  the  gray  or  whitish-blue 
colour.  In  a few  instances  they  are  jet  black, — a peculiarity 
which  seems  to  depend  on  a degree  of  black  infiltration,  or  on  the 
incipient  stage  of  that  change  which  has  been  termed  melanosis,  or 
melanotic  deposition.  The  idea  that  it  may  be  derived  from  the 
carbonaceous  matter  suspended  in  the  atmosphere  of  great  cities, 
has  been  shown  by  Cruikshank  to  be  absurd.  Its  anatomical  pos- 
sibility may  be  justly  questioned. 

They  are  always  situate  in  the  celluloso-adipose  tissue  found  in 
the  flexures  of  the  joints.  They  are  found  in  small  number  at  the 
bend  of  the  ham,  and  that  of  the  elbow  ; they  are  more  numerous 
in  the  arm-pit  and  groin  ; in  considerable  number  in  the  cellular 
tissue  of  the  lumbar  region,  before  the  psoas  and  iliacus  muscles; 
and  they  are  most  abundant  round  the  neck.  The  posterior  me- 
diastinum, and  the  cellular  tissue  between  the  mesentery  and  ver- 
tebral column,  abounds  with  lymphatic  glands  mutually  connected 
in  clusters. 

Each  gland  may  be  said  to  consist  of  a peculiar  substance,  in  j 


216 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


closed  in  a thin  membrane  like  a capsule.  The  capsule  is  a thin 
pellucid  colourless  suostance,  which  is  resolved  by  maceration  into 
fine  whitish  fibres.  It  is  very  vascular ; and  Mascagni  appears  to 
have  detected  absorbents  in  it.  It  is  connected  to  the  proper  sub« 
stance  by  fine  filamentous  or  cellular  tissue.  The  capsule  is  con- 
sidered by  Beclard  as  a fibro-cellular  membrane.  The  proper  sub- 
stance of  lymphatic  glands  consists  of  a homogeneous  pulp,  in 
which  injections  have  shown  numerous  ramifications  of  minute  ves- 
sels. As  these  vessels  are  injected  from  the  lymphatics  which  are 
seen  to  enter  the  body  of  the  gland,  they  are  believed  to  be  conti- 
nuous with  them,  and  to  be  lymphatics  arranged  in  a peculiar  man- 
ner. These  vessels  are  of  two  kinds,  one  entering  the  gland  called 
vasa  afferentia  or  inferential  entrant  lymphatics  ; the  other  quitting 
is  called  vasa  efferentia,  egredient  lymphatics.  This  distinction  is 
founded  on  the  direction  of  the  valves.  In  the  vasa  inferentia  the 
fi’ee  margins  of  the  valves  are  turned  toward  the  gland ; in  the  vasa 
efferentia  they  are  turned  from  it. 

The  number  of  entrant  lymphatics  varies  from  one  to  thirty,  and, 
what  is  more  remarkable,  almost  never  corresponds  with  that  of  the 
egredient  lymphatics,  which  are  in  general  much  fewer.  Cruik- 
shank  says  he  has  injected  fourteen  entrant  lymphatics  to  one  gland, 
to  which  only  one  egredient  vessel  corresponded.  When  the  en- 
trant lymphatic  reaches  the  gland  it  splits  into  many  radiated 
branches,  which  immediately  sink  into  its  substance.  The  egredi- 
ent lymphatics  are  generally  larger  than  the  entrants. 

The  arrangement  of  these  vessels  in  the  interior  of  the  glands  is 
best  described  by  Mascagni,  whose  observations  are  confirmed  by 
Gordon.  To  see  this  well,  it  is  requisite  to  inject  the  entrant  lym- 
phatics of  two  glands  in  two  different  modes ; one  with  mercury, 
the  other  with  wax,  glue,  or  gypsum.  After  a successful  mercu- 
rial injection,  the  entrants  are  seen,  before  sinking  in  the  gland,  to 
divide  into  two  orders  of  branches.  One  of  them,  which  belongs 
chiefly  to  the  surface  or  circumference  of  the  gland,  consists  of 
large  vessels,  bent,  convoluted,  and  interwoven  in  every  direction, 
communicating  with  each  other,  and  swelling  out  into  dilated  cells 
at  certain  parts,  and  of  smaller  vessels,  which  form  a minute  net- 
work on  the  surface,  and  which  seem  to  terminate  in  the  cells  or 
distended  parts  of  the  larger  vessels. 

From  these  distended  parts  or  cells,  again,  arise  many  minute 
vessels,  which,  after  winding  about  on  the  surface  of  the  gland, 
unite  gradually,  and  form  the  egredient  vessels  of  the  gland. 


LYMPHATIC  GLAND  OR  GANGLION. 


217 


The  wax,  glue,  or  gypsum  injection  is  employed  to  show  the 
deep-seated  or  central  vessels  of  the  gland.  The  distribution  of 
these  is  found  to  be  quite  the  same  as  that  of  the  superficial  vessels. 

The  cells  delineated  by  Cruikshank,  I am  disposed  to  regard 
as  mere  dilated  parts  of  the  lymphatic  vessels  which  constitute  the 
intimate  structure  of  the  gland. 

These  minute  tubes  are  connected  by  delicate  filamentous  tissue, 
which  is  more  abundant  in  early  life  than  afterwards. 

Injections  show  the  existence  of  blood-vessels,  which  accompany 
the  convolutions  of  the  lymphatics  in  the  glands.  But  no  nerves 
have  been  found  either  in  the  glands  or  their  capsules. 

The  white  matter  described  by  Haller  and  Bichat  is  not  con- 
tained in  the  cellular  substance,  but  in  the  cells  of  the  lymphatic 
vessels  themselves. 


Section  II. 

1.  a.  The  lymphatic  glands  as  organized  bodies,  may  be  sup- 
posed to  be  liable  to  ordinary  inflammation.  Yet  on  this  subject 
no  very  precise  facts  are  given.  The  swelling  called  bubo,  (/SouCwif, 
Hippocrates)  appears  to  be  in  most  cases  inflammation  of  the  cap- 
sule and  surrounding  cellular  substance. 

/3.  Adenosis.  Strumous  Inflammation.  The  glands,  however,  ap- 
pear to  be  liable  to  a slow  chronic  inflammation,  which  does  not 
readily  suppurate,  and  which,  when  it  does  suppurate,  always  forms 
a bad  and  tedious  disease.  They  ai’e  believed  to  be  often  affected 
in  scrofulous  subjects;  and  the  definition  of  the  evil  (struma,  scro- 
fula, les  ecrouelles,')  has  been  directly  taken  from  this  pnenomenon. 
In  such  affections  these  bodies  undoubtedly  become  the  seat  of  a 
slow  inflammatory  action,  which  is  attended  with  gradual  enlarge- 
ment, without  much  pain  or  change  of  colour  in  the  integuments. 
At  length,  the  gland  is  found  to  become  softer  than  it  had  been, 
and  an  opening  takes  place  in  the  skin,  through  which  a fluid  is 
discharged,  not  homogeneous,  but  in  general  consisting  of  a thin 
serous  water,  in  which  thicker  pieces  like  curd  are  mixed.  This 
fluid,  which  is  generally  most  completely  formed  in  suppuration  of 
the  lymphatic  glands,  is  what  has  been  termed  scrofulous,  or  stru- 
mous matter.  Simple  strumous  enlargement  in  these  glands  may 
proceed  to  such  an  extent  as  to  interfere  with,  and  even  impede  the 
functions  of  important  organs.  In  those  of  the  neck  they  have,  by 


218 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


compressing  the  windpipe,  caused  fatal  suffocation.  (Soemmering 
and  others.)  Bleuland  saw  them  in  an  infant  impede  deglutition 
hy  pressing  the  oesophagus,* 

7.  Adenitis.  Irritative  Enlargement.  The  lymphatic  glands  are 
liable  to  become  painful  and  enlarged,  in  consequence  of  causes  not 
originally  resident  in  themselves.  A sore  or  wound,  especially  if 
punctured  or  lacerated,  on  the  hand  or  foot,  may  be  succeeded  in 
a few  days  by  an  enlarged  painful  swelling  of  one  or  more  glands 
in  the  arm-pit  or  groin.  A wound  of  the  scalp  may  be  followed 
by  a glandular  swelling  of  the  neck  ; and  a spoilt  tooth,  or  a sore 
of  the  mouth,  will  often  give  rise  to  a painful  enlargement  of  the 
glands  under  the  jaw.  1 have  repeatedly  seen  a whole  chain  of 
them  enlarge,  and  continue  so  for  months,  in  consequence  of  the 
use  of  mercury  carried  to  salivation,  and  especially  after  enlarge- 
ment and  ulceration  of  the  muciparous  follicles  of  the  ileum,  whe- 
ther isolated  or  aggregated.  It  is  particularly  to  be  observed,  that 
when  these  follicles  of  the  aggregated  glands  become  prominent 
and  swelled,  or  atfected  by  ulceration,  which  usually  takes  place 
towards  the  lower  end  of  the  ileum,  then  the  mesenteric  glands  op- 
posite and  corresponding  to  these  intestinal  follicles  become  en- 
larged and  swelled  often  to  a great  degree.  The  enlargement  and 
swelling  seem  at  first  to  be  simple  enlargement  of  the  glandular 
parenchyma ; but  after  some  time  this  appears  to  contain  a new 
deposit,  which  appears  to  be  what  I have  called  tyromatous  matter. 
The  tracheo-bronchial  glands  become  enlarged  in  inflammation 
of  the  bronchial  membrane  of  the  pulmonic  tissue,  and  other  dis- 
eases of  the  lungs ; and  those  of  the  mesentery  increase  in  conse- 
quence of  disease  of  the  intestinal  canal.  In  such  instances  it  is  ob- 
vious that  irritation  at  the  organic  end  of  the  lymphatics  is  the 
cause  of  morbid  action  in  the  glands,  at  the  glandular  end  of  these 
vessels. 

In  other  instances,  for  example,  when  a sore  on  the  penis  is  fol- 
lowed by  enlargement  of  the  inguinal  glands,  or  a cancerous  breast 
is  attended  with  swelling  and  pain  of  the  axillary  glands,  it  has 
been  concluded,  that,  as  the  primary  diseases  depend  on  a peculiar 
or  specific  action,  as  it  was  termed,  peculiar  matter  is  absorbed,  and 
conveyed  to  the  gland,  in  which  it  gives  rise  to  the  morbid  changes. 
We  now  know  that  it  is  unnecessary,  in  the  majority  of  cases,  to 
suppose  absorption,  which  indeed  is  rendered  very  doubtful ; and 

* Obaervationes  de  sano  et  morbosa  (Esophagi  Structura.  Lugdun.  Bat.  1785. 


LYMPHATIC  GLAND  OR  GANGLION. 


219 


it  is  sufficient  to  ascribe  the  glandular  enlargement  in  such  instances 
to  mere  irritation  at  the  organic  ends  of  the  lymphatics. 

2.  Enlargement  from  the  Operation  of  Poisonous  Matter,  Pes- 
tilential Bubo.  In  plague  the  glands  of  the  arm-pit  and  of  the 
groin  generally  become  enlarged  as  the  disease  advances.  The 
period  at  which  this  takes  place  is  uncertain,  but  seems  to  vary 
from  the  first  twenty-four  hours  to  the  seventh  or  eighth  day. 
(Russel,  de  Mertens,  Orraeus,  &c.)  This  enlargement,  which  soon 
proceeds  to  a bad  open  sore,  accompanied  with  sloughing  and  the 
discharge  of  foul,  dirty-coloured  fluid,  has  been  generally  ascribed 
to  the  absorption  of  the  pestilential  poison,  and  its  direct  operation 
on  the  glandular  system.  This  is  probably  in  general  the  true  ac- 
count of  the  pestilential  bubo.  As,  however,  they  are  almost  in- 
variably accompanied  with  carbuncles,  it  is  not  unlikely  that  in 
some  instances  the  bubo  may  be  the  result  of  irritation  from  the 
presence  of  a carbuncle. 

3.  Enlargement  with  Death  of  the  Glandular  Tissue,  a.  Stru- 
mous Mortified  Bubo.  Of  strumous  bubo  there  are  many  varieties 
well  known  to  the  practical  surgeon.  To  this  head,  however,  I 
refer  a peculiar  disease  which  I have  seen  in  the  glands  at  the  bend 
of  the  arm.  The  glands  become  enlarged,  painful,  and  hard;  and, 
notwithstanding  all  efforts  to  procure  resolution,  the  skin  first  gives 
way,  chiefly  by  sloughing,  and  matter  with  some  membranous 
shreds  is  discharged.  A sore  of  a peculiar  character  is  formed^ 
Its  edges  consist  of  skin  cut  very  sharp,  and  notched  or  serrated, 
as  it  were,  into  angular  slips.  From  these  margins  the  sore  de- 
scends deep  and  rather  foul  to  an  ash -coloured,  solid,  convexly- 
rounded  body,  which  is  evidently  a diseased  gland.  Round  this  the 
process  of  suppuration  and  ulceration  proceeds,  with  the  occasional 
discharge  of  sloughs,  till  the  gland  is  expelled  either  in  fragments 
or  in  a mass.  After  which  the  hollow  is  filled  with  granulations, 
and  cicatrization  is  easily  effected. 

This  process  is  attended  with  pain  at  first  in  the  skin  chiefly,  but 
afterwards  it  seems  to  cause  no  more  uneasiness  than  an  ordinary 
abscess.  Its  duration  varies  according  to  the  size  and  number  of 
the  glands  to  be  ejected.  In  the  most  distinct  cases  which  I have 
seen,  it  occupied  between  three  and  four  months.  This  disorder  I 
regard  as  arising  from  a gland  being  suddenly  smitten,  as  it  were, 
with  death  in  its  intimate  structure,  from  previous  disease  of  its 
membranous  capsule  and  proper  vessels.  I have  seen  it  only  in 


220 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


those  at  the  bend  of  the  arm ; and  to  Cruikshank  it  appears  to 
have  occurred  in  the  same  situation.*  It  may  occur,  however,  and 
probably  has  been  seen  by  others  elsewhere. 

3.  Phagedenic  Buho.  Seen  principally  in  the  inguinal  glands 
in  persons  labouring  under  the  operation  of  the  syphilitic  poison, 
or  who  have  been  subjected  to  repeated  courses  of  mercurial  medi- 
cines. The  skin  first  becomes  hard,  painful,  hot,  and  dull  red, 
with  circumscribed  edge,  but  dififusely  swelled.  The  transition  to 
a dirty  grayish-brown  indicates  that  the  skin  has  become  dead  ; 
and  the  process  of  ulceration,  alternating  with  sloughing,  is  esta- 
blished. As  the  skin,  and  successively  the  cellular  tissue,  are 
thrown  off  in  this  manner,  one,  two,  or  more  glands  come  into 
view,  somewhat  swelled,  and  of  a brownish-red  colour,  but  equally 
distinct  as  if  they  had  been  carefully  dissected.  The  surface  of  the 
sore  is  generally  a deep-red  brown,  covered  with  a foul  blood-co- 
loured serous  fluid,  without  appearance  of  granulations,  and  with 
the  sensation  of  burning  or  searing  pain.  The  process  of  sloughing 
proceeds  in  the  cellular  tissue,  while  the  gland  or  glands  remain 
as  so  many  brownish  masses,  with  small  marks  of  vitality,  until 
they  are  detached  entirely  from  the  cellular  substance,  in  which 
they  are  imbedded,  and  are  thrown  off  dead.  In  effecting  this 
object,  the  process  of  sloughing  may  proceed  to  such  extremity  as 
to  affect  first  the  superincumbent  cellular  coat,  and  next  the  sheath 
of  the  femoral  artery,  which,  in  such  circumstances,  inevitably 
gives  way  ; and  the  patient  is  suddeidy  destroyed  by  hemorrhage. 
An  instance  of  this  accident  in  a soldier  of  the  guards  used  to  be 
mentioned  by  Dr  Hunter.f  In  a case  which  occurred  some  years 
ago  in  the  military  hospital  of  the  Castle,  it  was  deemed  requisite 
to  avert  the  impending  danger  by  tying  tbe  femoral  artery.  Sub 
sequent  gangrene  of  the  foot  and  leg,  however,  rendered  amputa- 
tion indispensable  ; and  recovery  at  length  took  place. 

In  more  favourable  circumstances,  after  great  destruction  of 
parts,  and  the  expulsion  of  one,  two,  or  more  mortified  glands,  the 
phagedenic  action  stops  spontaneously,  granulation  takes  place, 
and  the  sore  is  gradually  healed. 

I have  described  the  progress  and  phenomena  of  this  disease,  as 
I have  witnessed  them  in  several  instances  which  have  fallen  under 

* “ I have  known  the  last  mentioned  glands  (the  bracliial)  die,  and  slough  out  in 
scrofula  without  any  great  inconvenience.” — The  Anatomy  of  the  Absorbing  Vessels, 
p.  132. 

-f-  The  Anatomy  of  the  Absorbing  Vessels,  p.  122,  p.  134,  second  edition. 


LYMPHATIC  GLAND  OR  GANGLION. 


221 


my  observation.  It  appears  that  the  active  symptoms  manifest 
themselves  first  in  the  skin  and  cellular  membrane ; and  it  may 
therefore  he  thought  that  the  disease  belongs  properly  to  these  tis- 
sues. Their  affection,  nevertheless,  is  so  far  as  can  be  determined, 
the  result  of  the  previous  state  of  the  glands,  which  appear  to  he 
directly  killed  either  by  the  syphilitic  poison,  or  the  mercurial  ac- 
tion, and  thus  to  give  rise  to  the  violent  process  of  disorganization, 
which  then  takes  place  in  the  skin  and  cellular  membrane. 

Enlargement  of  the  mesenteric  glands  has  been  supposed  by 
most  authors  to  be  the  anatomical  characters  of  the  disease  term- 
ed mesenteric  wasting — {Tales  mesenterica.  Tabes  glandularis. 
Wharton,  Baglivi,  Richard  Russell.)  Without  absolutely  deny- 
ing this,  I shall  afterwards  show,  that,  in  most  instances  of  that  dis- 
ease, the  enlargement  of  the  glands  is  secondary  to  some  morbid 
state  either  of  the  intestinal  villous  membrane,  the  muciparous  fol- 
licles, or  of  some  of  the  intestinal  tissues. 

4.  Enlargement  and  Induration.  ( Vascular  Sarcoma.)  Either 
after  repeated  attacks  of  inflammation,  alternating  with  resolution, 
or  with  a slow  and  indistinct  form  of  the  disease,  a gland,  or  a 
cluster  of  glands  gradually  enlarges,  and,  resisting  all  means  of 
resolution,  becomes  unusually  hard.  This  continues,  or  is  liable 
to  slight  occasional  aggravations,  with  dull  pain  in  the  substance, 
or  in  the  neighbourhood  of  the  gland.  Though  such  enlargement 
may  be  termed  strumous.^  and  may  have  originated  in  what  is  termed 
strumous  action,  the  structure  of  the  gland  or  glands  is  so  much 
changed  as  not  to  be  distinguished  from  vascular  sarcoma.  A 
tumour  of  this  kind,  when  divided,  presents  a firm  homogeneous 
substance  of  a bluish-gray  colour,  somewhat  elastic  and  compres- 
sible, traversed  with  more  or  fewer  vessels  which  may  be  injected 
from  the  neighbouring  arteries,  and  consisting  in  its  intimate 
structure  of  amorphous  granular  masses  united  by  dense  filamen- 
tous tissue.  The  great  hardness,  and  the  malignant  tendency  of 
this  growth,  have  procured  for  it  from  most  authors  the  ominous 
names  of  scirrhus  and  cancer.  Though  correct  enough  for  all 
practical  purposes,  these  epithets  are  not  justified  by  the  anatomi- 
cal characters. 

Sarcomatous  enlargement  may  occur  in  any  of  the  lymphatic 
glands.  It  is  frequent  in  those  of  the  neck,  and  may  often  be  trac- 
ed to  strumous  inflammation,  or  to  the  irritation  of  spoiled  teeth. 
Cruikshank  mentions  an  instance  in  which  the  tracheo-bronchial 


222 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


lymphatic  glands  were  atFected  with  this  morbid  change  to  such  ex- 
tent as  to  cause  fatal  suffocation.*  In  the  internal  iliac  glands  it 
is  not  uncommon,  so  as  to  form  large  indurated  masses  ; and  in  the 
female  may  operate  as  a cause  of  difficult  parturition  equally  fatal 
to  the  mother  and  the  infant.  (Hunter  apud  Cruikshank.)f  The 
same  disease  occurs  in  the  mesentery  either  primarily,  or  in  con- 
sequence of  ulceration  of  the  intestines. 

5.  Tyroma  glandularum.  Tyromatous  deposition.  Tubercular 
deposition.  The  lymphatic  glands  are  liable  to  become  the  seat  of 
a deposit  of  matter  different  in  all  appearances  from  their  own  tis- 
sue. The  gland  or  glands  so  affected  may  either  be  enlarged  or 
not ; but  in  almost  all  cases  they  are  eventually  enlarged,  sometimes 
to  three,  four,  or  even  six  times  their  natural  size.  Their  shape 
they  sometimes  retain,  sometimes  not,  becoming  irregular  on  the 
surface,  lobulated,  and  generally  projecting  considerably  in  the 
free  or  unattached  direction.  When  divided  by  incision,  the  sec- 
tion presents  not  the  usual  bluish  or  pale-red  tint  of  the  healthy 
lymphatic  gland  ; but  a colour  cream-yellow,  gray,  or  whitish  gray. 
Nor  is  this  colour  always  uniform  ; for  in  one  lymphatic  gland  in 
a cluster  it  is  cream-yellow,  or  grayish,  and  in  another  it  is  of 
white  colour,  and  sometimes  this  difference  is  seen  in  different  parts 
of  the  same  gland.  In  this  material  few  or  no  vessels  are  recog- 
nised. The  whole  is  more  or  less  a homogeneous  matter  of  gray 
or  cream-yellow  colour,  like  soft  cheese,  pretty  firm  and  resisting ; 
and  it  presents  to  the  glass  no  arrangement  of  cells  or  vessels,  but 
a confused  mass  of  substance  with  no  trace  or  mark  of  organiza- 
tion. This  has  been  called  cheesy  or  caseous  substance ; and  in 
those  cases  in  which  it  is  deposited  in  the  form  of  small  spherical 
or  spheroidal  globules,  it  has  been  named  tubercle,  and  tubercular. 
I think  that  the  term  Tyroma  (Tu^og,  caseus,)  is  most  suited  to  ex- 
press its  nature  and  most  obvious  characters. 

This  tyromatous  substance  is  effused  in  the  fluid  or  semifluid 
form,  and  then  gradually  acquires  the  consistent  character.  It  ap- 
pears in  several  instances  to  be  effused  at  different  points  of  the 
gland ; and  hence  the  consistence  and  colour  is  different  at  different 
points.  In  the  most  fluid  form  it  is  like  thickish  cream,  or  a mix- 
ture of  chalk  and  water.  In  others  more  consistent  the  matter 
contained  is  like  soft  putty,  or  consists  of  consistent  granules  diffus- 
ed in  a whey  like  or  milk  like  fluid.  This  is  what  is  often  called 

* Anatomy  of  the  Absorbing  Vessels,  p.  129.  -f  Ibid.  p.  123. 


LYJIPHATIC  GLAND  OR  GANGLION. 


223 


pultaceous  matter  and  atlieromatous  matter.  In  some  of  these  ty- 
romatous  deposits  are  observed  portions  much  firmer,  sometimes  as 
hard  as  cartilage,  and  in  some  as  solid  as  earthy  or  stony  matter. 

This  deposit  of  earthy  or  bony  matter  also  takes  place  in  the  li- 
quid or  semifluid  form,  and  gradually  becomes  thick  and  consis- 
tent by  the  absorption  of  the  serous  or  most  fluid  part ; and  the 
earthy  or  gypseous  portion  shows  its  true  nature  by  becoming  solid 
and  its  particles  coalescing. 

This  deposit  is  liable  to  take  place  in  any  of  the  glands.  It  is, 
however,  most  common  in  the  bronchial  lymphatic  glands  and  in  the 
mesenteric  lymphatic  glands,  and  in  the  lymphatic  glands  of  the 
neck.  In  the  bronchial  lymphatic  glands  it  is  mostly  a disease  of 
infancy,  certainly  of  early  life.  I have  not  seen  it  much  in  adults; 
but  I have  repeatedly  met  with  it  in  dissecting  the  bodies  of  infants 
and  children ; and  many  of  the  thoracic  and  tracheal  affections  to 
which  children  are  liable  may  either  he  traced  to  or  are  associated 
with  the  presence  of  enlarged  and  tyromatous  bronchial  glands. 
This  may  be  caused  by  the  fact,  that  most  children,  in  whom  the 
bronchial  glands  are  tyromatous,  die  in  childhood. 

Enlargement  of  the  bronchial  and  tracheal  glands  gives  rise  to 
great  dyspnoea,  and  sometimes  to  symptoms  of  crowing  inspiration. 

In  the  glands  of  the  neck  it  is  less  hurtful,  not  being  a cause  of 
disease  in  the  lungs  or  trachea ; and  hence  it  continues  longer  with- 
out influencing  much  the  duration  of  life. 

In  the  abdomen,  on  the  other  hand,  it  is  different.  For  there  it 
evidently  compresses  the  lacteals  proceeding  from  the  intestinal  tube. 
At  the  same  time  it  is  there  seldom  alone,  but  is  preceded  by  more 
or  less  disease,  often  enlargement  and  ulceration  of  the  intestinal  fol- 
licles, as  was  mentioned  when  speaking  of  common  glandular  en- 
largement. 

This  species  of  deposit  takes  place  chiefly  in  those  in  whom  the 
habit  called  strumous  predominates.  It  is  supposed,  indeed,  to  be 
the  effect  and  an  indication  of  the  strumous  disposition;  and  such  pro- 
bably it  generally  is.  Though  not  a heterologous  deposit,  and  con- 
sisting entirely  of  crude  albumen  insusceptible  of  organization,  yet  it 
is  in  its  consequences  suflBciently  hurtful.  When  large  tyromatous 
glands  compress  the  bronchial  tubes  and  lungs,  and  cause  cough 
and  difficult  and  laborious  breathing,  they  may  also  by  their  size 
and  position  compress  important  blood-vessels  and  seriously  de- 
range the  circulation. 

Tyromatous  glands,  after  becoming  consistent,  are  liable  to  under- 


224 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


go  an  ulterior  stage  of  softening,  and  apparently  almost  ulcerative 
sloughing.  Thus  we  find  them  soften  and  suppurate  iu  the'neck  and 
groin  ; and  after  a tedious  process  of  suppuration  subside  and  dis- 
appear, leaving  bad  and  indelible  scars  with  much  irregular  con- 
traction of  the  skin.  In  the  bronchial  glands,  when  tyromatous,  I 
have  seen  them  in  like  manner  softened  and  converted  into  a sort  of 
cream-like  sero-purulent  matter  ; and  others  presenting  deep  ragged 
ulcerated  cavities.  Lastly,  in  the  mesentery,  where  they  are  often 
allowed  to  pass  through  all  their  stages  before  the  death  of  the  pa- 
tient, it  is  not  uncommon  to  find  the  glands  in  different  stages  of 
softening.  One  or  two  are  firm  and  consistent;  others  present 
softening,  taking  place  at  different  points  ; others  present  portions 
of  cream-like  or  soft  caseous  purulent  matter ; and  others  are  re- 
presented by  bags  of  puriform  atheromatous  semifluid  substance, 
which  is  the  tyromatous  matter  dissolved  or  liquefied,  contained 
within  the  capsule  or  tunic  of  the  gland,  the  only  persistent  por- 
tion of  the  whole  structure. 

The  tubercular  disorganization  is  represented  by  Laennec, 
Dupuy,  and  others,  as  exceedingly  frequent  in  lymphatic  glands. 
By  some  authors  these  bodies  are  regarded  as  constituting  the  ana- 
tomical character  of  the  strumous  or  scrofulous  gland.  In  many 
instances  of  scrofulous  enlargement  and  induration,  the  glands  are 
indeed  found  to  be  occupied  with  minute  bodies,  somewhat  firm, 
which  undergo  a slow  liquefaction  or  mollescence.  But  it  is  per- 
haps too  limited  a view  to  restrict  to  this  only  the  characters  of 
scrofula.  In  some  instances  these  tubercles  appear  to  consist  of 
the  original  cells  of  the  gland,  filled  with  albuminous  or  albumino- 
calcareous  matter. 

6.  Ossification,  Calcareous  Deposition.  The  lymphatic  glands 
are  liable  to  become  ossified,  or  to  be  penetrated  with  deposition  of 
calcareous  matter.  The  diseased  action  commences  at  one  or  more 
points,  and  is  progressively  extended,  till  the  gland  is  converted 
into  a bony  mass.*'  This  change  was  observed  by  Cruikshank  in 
the  tracheo-bronchial  glands,  which  he  represents  as  in  that  state 
producing  ulceration  through  the  trachea,  and  being  coughed  up 
as  osseous  concretions. Baillie,  adopting  the  same  view,  regards 
the  calcareous  deposition  as  more  common  in  these  bodies  than  in 
any  other  of  the  same  texture.J  Lastly,  Bayer  has  observed  this 

* A Practical  Essay  on  the  Diseases  of  the  Vessels  and  Glands  of  the  Absorbent 
System,  &c.  By  William  Goodlad,  Surgeon,  &c.  p.  74.  London.  1814. 

■f  Anatomy,  &c.  p.  129.  Morbid  Anatomy. 


ORGANIZATION  AND  STRUCTURE. 


225 


change  not  only  in  the  tracheo-bronehial  glands  in  subjects  which 
he  terras  phthisical,  but  in  the  cervical  glands  in  laryngeal  con- 
sumption, and  occasionally  in  persons  cut  off  by  mesenteric  scro- 
fula, {carreau^)  and  in  tbe  inguinal  glands  in  persons  who  have 
had  buboes.  This  change  he  considers  the  effect  of  inflammation.* 
To  the  same  head  are  to  be  referred  the  earthy  or  calcareous  de- 
positions (rnatiere  platreuse,  gypseuse)  observed  by  Dupuy  in  these 
glands. 

7.  Melanotic  deposition  is  common  in  the  tracheo-bronchial  lym- 
phatic glands,  and  in  those  of  the  groin.  Of  the  former,  an  ex- 
ample is  at  the  present  moment  before  me  in  the  lungs  of  a woman 
much  occupied  by  tubercular  masses. 


CHAPTER  XII. 

The  three  orders  of  tubes  or  canals,  the  anatomical  characters, 
and  pathological  relations  of  which  have  now'  been  completed,  con- 
stitute what  has  been  termed  tbe  Vascular  System,  ( Vasa  ; Sys- 
tema  Vasorum,  Das  Gefass  System.  Le  Systems  Vasculaire.) 
The  great  extent  of  its  distribution,  and  the  part  which  it  performs 
in  all  the  processes  of  the  living  body,  both  in  health,  and  during 
disease,  must  be  easily  understood.  In  every  texture  and  organ 
arteries  and  veins  are  found ; and  in  all,  except  a few,  the  art  of 
the  anatomist  has  demonstrated  those  colourless  valvular  tubes  de- 
nominated lymphatics.  The  arrangement  of  the  former,  especially 
in  the  substance  of  the  several  textures,  essentially  constitutes  what 
is  termed  the  organization  of  these  textures.  IMany  anatomists 
have  imagined  that  each  texture  has  a proper  matter,  or  paren- 
chyma^ by  which  it  was  supposed  to  be  particularly  distinguished, 
and  which  was  conceived  to  consist  of  minute  inorganic  solid  atoms. 
"Whether  this  opinion  be  w'ell  founded  or  not,  it  is  perhaps  of  little 
moment  to  inquire.  At  present  it  is  certain  that  it  is  not  suscep- 
tible of  demonstration. 

The  phenomena  of  injections,  in  which  he  was  eminently  suc- 
cessful, led  Ruysch  to  entertain  the  opinion,  that  every  substance 

* Memoire  sur  I’ossification  morbide,  consideree  comme  une  terrainaison  dc®.  phleg- 
niasies.  Par  P.  Raver.  Archives  Generales,  Tome  I.  p.  439, 

P 


226 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


of  the  animal  frame  consisted  of  nothing  but  vessels.  This  idea, 
though  opposed  by  Albinus,*  on  the  same  grounds  on  which  it  was 
advanced,  was  nevertheless  revived  by  William  Hunter,  who  be- 
lieved that  the  inorganic  parts  of  animal  bodies  are  too  minute  for 
sensible,  or  even  microscopical  examination.  In  every  part,  how- 
ever  minute,  always  excepting  nails,  hair,  tooth  enamel,  &c.,  ves- 
sels could  be  traced ; and  even  a cicatrix  he  demonstrated  is  vas- 
cular to  its  centre,  f 

By  the  aid  of  the  microscope  the  researches  of  Lieberkuhn  tend- 
ed still  more  powerfully  to  favour  this  opinion.^  But  repeated 
observation  of  the  effects  of  injection  in  every  part  and  texture  al- 
most of  the  body  by  Barth  and  Prochaska  has  led  the  latter  to  con- 
clude, that  this  opinion,  understood  in  the  ordinary  mode,  is  not 
tenable.  Prochaska,  who  has  investigated  this  subject  with  much 
attention,  thinks  he  is  justified  in  dividing  all  the  substances  of  the 
animal  frame  into  two, — those  which  may  be  injected  and  those 
which  cannot.  In  this  manner  he  regards  skin,  especially  its  outer 
surface,  muscle,  various  parts  of  the  mucous  membranes,  the  pia 
mater^  the  lungs,  the  muscular  part  of  the  heart,  the  spleen,  the 
liver,  kidneys,  and  other  glands  as  very  injectible ; but  tendon,  li- 
gament, cartilage,  &c.  as  not  injectible.§  Without  entering  mi- 
nutely into  the  merits  of  this  distinction,  or  the  inferences  which 
Prochaska  makes  to  flow  from  it,  it  is  sufficient,  so  far  as  all  useful 
knowledge  is  concerned,  to  infer,  that  blood-vessels  are  an  essential 
constituent  of  every  organic  texture,  however  different;  and,  if 
there  be  any  other  matter  inherent  in  such  textures,  it  must  be 
derived  from  these  as  a secretion.  Muscle,  brain,  nerve,  osseous 
matter,  and  cartilage  are  depositions  or  the  product  of  nutritious 
secretion  from  the  respective  arteries  of  these  organized  substances. 

To  apply  these  distinctions  to  pathological  anatomy,  therefore, 
two  leading  facts  are  presented  as  principles.  The  first  of  these  is 
the  arrangement  of  the  vessels  in  the  substance  of  the  organic  tex- 
tures ; — their  organization.  The  second  is  the  great  result  of  or- 
ganization, the  principal  duty  performed  by  the  vessels  in  each  tis- 
sue ; — the  formation  of  each  organic  substance,  or  the  process  of 

* Annotationum  Academicarum,  Lib.  iii. 

t Medical  Observations  and  Inquiries,  Vol.  II. 

:}:  De  Villis  Intestinorum. 

§ Georgii  Prochaska  Disquisitio  Anatomica-Physiologica  Organismi  Corporis  Hu- 
mani  ejusque  Processus  Vitalis,  4to.  Vienna,  1812. 

4 


OEGANIZATION  AND  STRUCTURE. 


227 


nutrition.  To  changes  in  one  or  other  of  these  two  circumstances 
almost  all  morbid  actions  which  become  the  subject  of  pathological 
anatomy  may  be  referred;  under  the  two  general  divisions,  of 
changes  in  organization ; and,  2d,  changes  in  nutritious  deposition, 
or  intimate  structure. 

It  is  unnecessary  to  render  this  division  more  complex,  by  ad- 
mitting, as  has  been  done  by  several  pathological  writers,  a third 
head  in  the  changes  which  take  place  in  the  process  of  secretion. 
That  process  is  to  be  viewed  in  general,  nay,  in  almost  all  circum- 
stances, as  a complementary  effect  of  nutrition ; and  the  morbid 
changes  which  it  occasionally  undergoes  may,  without  violence,  be 
referred  to  one  or  other  of  the  two  foregoing  heads. 

It  is  different,  however,  with  a third  form  or  source  of  disease. 
I allude  to  those  errors  in  the  formation  and  relative  situation  of 
parts,  especially  the  integrant  parts  of  organs,  which  have  been 
termed  malformations,  (Missbildungen.)  These  have  been  shown 
by  Oken,  Meckel,  and  others,  to  depend  on  the  accidental  inter- 
ruption of  the  process  of  development,  and  misapplication  of  the 
component  parts  of  organs  during  the  early  stage  of  that  process. 

In  the  subsequent  chapters  of  this  work,  though  it  is  unnecessary 
to  abandon  the  simple  arrangement  hitherto  observed,  the  morbid 
changes  incident  to  the  several  textures  shall  be  enumerated  in  re- 
ference to  the  two  first  distinctions, — those  in  minute  organization 
and  its  products,  and  those  in  nutrition  and  intimate  structure. 
The  various  forms  of  malformation  constitute  a distinct  family  by 
themselves. 


BOOK  II. 

THE  NERVOUS  SYSTEM. 


The  nervous  systena  of  the  animal  body  ineludes,  according  to 
the  most  rational  views,  two  general  divisions.  The  first  of  these 
is  collected  in  a single  and  indivisible  mass,  and  contained  in  a pe- 
culiar cavity,  formed  by  part  of  the  osseous  system  of  the  animal. 
In  the  less  perfect  tribes  this  is  limited  to  the  vertebral  column,  or 
sometbing  analogous  to  it ; but  in  man,  and  the  more  perfect  ani- 
mals, we  find  a lai'ge  cavity  at  the  superior  extremity  of  this  column 
superadded.  The  second  division  of  the  nervous  system  is  found 
in  the  form  of  long  chords  or  threads  mutually  connected,  and 
running  in  various  directions  through  the  body  in  the  mode  of  ra- 
mification, To  these  the  name  of  nervous  trunks  or  chords,  or 
simply  nerves,  has  been  long  applied. 


CHAPTER  I. 

A.  The  Central  Part  of  the  Nervous  System. 

Section  I. 

BRAIN,  CEREBRAL  SUBSTANCE,  Cerebrum^ — BRAIN,  cranial  and 
SPINAL.  MviXov  ey/.i(puXo\/  nai  fjjViXov  vunam  ; — Marrow  of  the 
Head  and  Marroio  of  the  Bach,  Galen. 

Of  all  the  works  which  have  been  composed  on  the  anatomy  of 
the  brain,  the  subjects  may  be  referred  to  two  general  heads  ; — 
those  which  treat  of  the  configuration  of  the  organ,  and  those  which 
undertake  to  investigate  its  minute  structure.  The  authors  them- 
selves, however,  do  not  always  distinguish  accurately  between  these 
two  departments  of  anatomical  science.  As  it  is  chiefly  the  latter 
which  is  to  occupy  attention  at  present,  I may  mention,  that  after 
the  epistle  of  Varoli  on  the  base  of  the  brain  and  the  origin  of  the 
optic  nerves,  the  writings  of  Willis,  Malpighi,  and  Vieussens,  are 


BRAIN, 


229 


the  first  which  claim  much  notice.  The  works  of  Ridley,* * * §  and  of 
Glaserus,t  contain  some  good  observations ; and  that  of  Santorini^ 
deserves  to  be  mentioned  for  the  first  good  description  of  the  optic 
thalarni  and  the  corpora  geniculata.  Father  Della  Torre, § Pro- 
chaskaj  and  Monro,  are  the  first  after  Lewenhoeck  who  treat  of 
the  structure  of  the  brain  after  microscopical  observation.  The 
essay  of  Vicq-D’Azyr,  and  his  elaborate  engravings  are  sufficiently 
well  known.^  About  the  same  time,  1780,  Vincenzo  Malacarne 
described  the  component  parts  of  the  organ  with  more  accuracy 
than  had  hitherto  been  attempted.** * * §§  Red  followed,  and  communi- 
cated much  new  information  on  the  minute  structure  of  several 
parts  of  the  organ.jf  The  work  of  Rolaudo,  which  appeared  in 
1809,J+  has  been  little  known  till  of  late.  Better  fortune  awaited 
the  elaborate  treatise  of  John  and  Charles  \Venzel,§§  which  is 
highly  appreciated  by  every  anatomical  inquirer  in  Europe. 
Lastly,  the  description  of  Gordon,  1|||  the  microscopical  observations 
of  Sir  Everard  Home,W  who  has  confirmed  many  of  the  facts  ob- 
served by  Della  Torre,  and  the  microscopical  observations  of 
Ehrenberg,  who  has  examined  every  part  of  the  brain  with  much 
care,  and  those  of  Treviranus,  Valentin,  and  Weber,  are  entitled 
to  attention. 

The  brain  may  be  considered  as  a continuous  organ  consisting 
of  three  divisions; — the  convoluted,  the  laminated,  and  the  smooth 
or  uniform  portions.  Of  these  divisions,  which  are  framed  accord- 
ing to  the  peculiar  external  configuration  of  each,  the  first  part 

* Anatomy  of  the  Brain.  By  Henry  Ridley.  Lend.  1695. 

•f-  J.  H.  Glaserus  de  Cerebro.  Basil,  1680. 

+ Jo.  Dom.  Santorini  Observationes  Anatomicse.  Lugdvm.  Bat.  1739. 

§ D.  Giovanni  Maria  Della  Torre,  Nuove  Osservazione  Microscopicbe.  Napoli, 
1776. 

II  Georgii  Prochaska,  De  Structura  Nervorum  Tractatus  Anatom.  Viennae,  1779, 
et  apud  Op.  Min.  1800. 

^ Recherches  sur  la  Structure  du  Cerveau.  Memoires  de  I’Academie  des  Sciences. 
Paris,  1781-83. 

**  Encefalotomia  Nuova  Universale  di  Vincenzo  Malacarne  Saluzzese.  Torino, 
1780. 

■It  Fragmente  Ueber  die  Bildung  des  Gehbns  im  Menschen.  Vom  Professor  Reil. 
Archiv.  fur  die  Physiogie.  8ter  Band,  &c.  et  various  papers  in  9ter  Band.^ 

Saggio  sulla  vera  Structura  del  cervello  dell’  uomo.  Sassari,  1809. 

§§  J.  et  C.  Wenzel,  De  Penitiore  Structura  Cerebri  Hominis  et  Brutorum.  Tubin- 
gs, 1812. 

III!  Observations,  &c.  and  Outlines  of  Human  Anatomy.  By  John  Gordon,  M.  D. 
&c.  Edinburgh. 

in  Phil.  Trans.  1821,  p.  25,  1824,  p.  1,  and  1825,  p.  436. 


230 


GENERAL  AND  PRTHOLOGICAL  ANATOMY. 


corresponds  to  what  is  called  the  brain  proper,  {cerebrum  ;)  the  se- 
cond to  the  small  brain,  {cerebellum  ;)  and  the  third  to  the  oblong 
cylindrical  body  contained  within  the  vertebral  column,  and  known 
under  the  name  of  spinal  chord. 

The  convoluted  portion  presents  two  surfaces,  an  outer  or  con- 
voluted, and  an  inner  or  figurate.  The  laminated  portion  in  like 
manner  presents  two  surfaces,  an  outer  or  laminated,  and  an  inner 
or  central.  The  third  has  only  one  exterior  surface. 

The  exterior  surface  of  the  convoluted  division  of  the  organ  is 
formed  into  eminences  longitudinal  and  rounded,  but  directed  in 
various  ways,  and  separated  from  each  other  by  deep  hollows. 
These  eminences  have  been  named  convolutions  or  circumvolutions, 
{gyri,  Soemmering,  Wenzel,)  and  the  depressions  swfe’ or  furrows. 
This  surface  of  the  organ  is  most  properly  termed  the  convoluted 
surface.  To  see  it  distinctly,  the  vascular  membrane  termed  pia 
mater.,  {meninx  tenuis,)  (Das  Gefasshaut,)  must  be  cautiously  re- 
moved by  dissection. 

The  convoluted  surface  communicates  with  another  interior  sur- 
face at  two  parts ; 1st,  on  the  middle  plane,  under  the  posterior 
end  of  the  middle  band  or  meso-lobe,  {corpus  callosum ;)  2d,  on 
each  side  of  the  middle  plane,  at  the  outer  margin  of  the  fluted 
masses  termed  limbs  of  the  brain,  {crura  cerebri) ; (Die  Hirnschen- 
kel) ; between  these  limbs  and  the  posterior  end  of  the  optic  cham- 
ber or  couch,  {thalamus  opticus)',  (Der  Sehhugel.)  This  surface  of 
the  organ  may  be  termed  the  central  or  figurate. 

The  exterior  surface  of  the  cerebellum  is  differently  disposed. 
Instead  of  presenting  convoluted  eminences,  it  consists  of  thin  por- 
tions of  cerebral  substance,  placed  contiguously,  and  either  paral- 
lel or  concentric.  These  portions,  which  have  been  named  plates 
{lamiruB,)  or  leaves  {folia,)  are  separated  from  each  other  by  fur- 
rows of  various  depth.  This  surface,  which  may  be  named  the 
laminar  or  foliated  surface  of  the  small  brain,  communicates  also 
with  the  figurate  surface;  Isf,  at  its  superior  part  on  the  middle 
plane,  between  the  semilunar  notch  (Der  halbmondformige  Aus- 
schnitt;  Reil);  behind,  and  the  white  cerebral  plate  termed  Vieus- 
senian  valve,  before.  2d,  At  its  inferior  surface  between  the  parts 
termed  almonds  by  Malacarne,  or  spinal  lobules  by  Gordon  above ; 
and  the  upper  end  {medulla  oblongata)  of  the  spinal  chord,  below. 

The  convoluted  surface  of  each  hemisphere  may  be  convenient- 
ly divided  into  the  following  five  regions;  1.  The  commutual  or 


BRAIN. 


231 


dichotomous ; 2.  The  lateral-superior,  or  convex ; 3.  The  antero- 
inferior, or  frontal ; 4.  The  medio-inferior,  or  spheno-temporal ; 
5.  The  posterior  or  cerebellic  region  of  the  convoluted  surface. 

The  first  of  these  regions  of  the  convoluted  surface  is  easily  un- 
derstood. Plane  in  its  surface,  of  a shape  nearly  semicircular,  it 
forms  the  central  boundary  of  each  hemisphere,  corresponds  to  the 
falciform  or  dichotomous  portion  of  the  hard  membrane, 

meninx  dura,)  by  which  it  is  separated  from  the  similar  sur- 
face of  the  opposite  hemisphere.  Before  and  behind  it  extends 
from  the  superior  to  the  inferior  surface  of  the  brain  ; but  a consi- 
derable portion  of  its  middle  is  terminated  by  the  upper  surface  of 
the  object  named  middle  band,  (mesolobe,  corpus  callosum,)  which 
lies  between  the  two  hemispheres.  It  is  contained  between  the  se- 
micircular and  the  rectilineal  margins. 

The  second  region  of  the  convoluted  surface  is  extensive,  and 
occupies  the  whole  of  the  anterior,  upper,  lateral,  and  posterior 
parts  of  the  hemisphere,  from  their  anterior  to  their  posterior  ex- 
tremity, and  from  the  semicircular  m.argin  to  a line  which  extends 
between  these  extremities  along  the  lateral  borders  of  the  organ. 

The  antero-inferior,  or  frontal,  is  that  region  of  the  convoluted 
surface  which  rests  on  the  horizontal  part  of  the  frontal  and  eth- 
moid bones,  and  commencing  before  with  a curved  outline, — the 
anterior  end  of  the  hemisphere  is  bounded  behind  by  the  curvili- 
near hollow,  which  has  been  named  the  pit  or  fissure  of  Sylvius. 
It  is  slightly  uneven,  and  is  bounded  at  its  inner  or  mesial  margin 
by  the  great  fissure  which  separates  the  hemispheres.  This  inner 
margin  always  presents  one  convolution,  which  is  quite  uniform  in 
direction,  extent,  and  configuration.  It  consists  of  a longitudinal 
eminence,  which  extends  in  the  adult  brain  about  1^  inch  from  the 
beginning  or  posterior  end  of  the  notch,  towards  its  anterior  ex- 
tremity. The  inner  margin  of  the  eminence,  which  is  about  four 
lines  broad,  forms  the  side  of  the  fissure  ; and  its  outer  margin  or 
border  is  separated  from  the  contiguous  part  of  the  convoluted  sur- 
face, by  a furrow  or  hollow  equally  uniform  in  direction  and  figure 
with  the  eminence, — about  the  same  average  length  (1  inch  5 lines.) 
This  furrow  contains  the  cerebral  portion  of  the  first  pair  or  olfa- 
cient  nerves. 

The  medio-inferior,  or  spheno-temporal,  is  sitnate  immediately 
beliind  this  region,  from  which  it  is  separated  by  the  curvilinear 
hollow.  {Fossa  Sylvii.)  In  the  ordinary  descriptions,  this  forms 
what  has  been  named  the  middle  lobe  of  the  brain  ; while  the  pos- 


232 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


terior  part  of  the  convoluted  surface,  or  that  which  corresponds  to 
the  cerebellum,  though  distinguished  by  no  evident  mark  or  limit, 
has  been  with  equal  impropriety  named  the  posterior  lobe.  If 
the  whole  region  be  examined  from  the  curvilinear  hollow  to 
the  posterior  tip  of  the  hemisphere,  it  affords  no  mark,  line,  or 
boundary  on  which  to  establish  this  popular  and  much  used  di- 
vision ; and  the  whole  presents  one  uniform  region  of  convolu- 
tions, which  resemble  in  every  respect  those  found  on  other  paits 
of  this  surface.  The  whole  region,  therefore,  ought  to  be  viewed 
as  a single  division  of  the  convoluted  surface ; but  as  its  posterior 
part  rests  not  on  the  cranium,  but  on  tbe  horizontal  portion  of  the 
hard  membrane  which  covers  the  small  brain,  while  the  division  of 
lobes  must  be  discarded  as  artificial,  it  may  be  expedient  to  subdivide 
the  surface  into  two,  the  medio-inferior  and  postero-inferior  regions 
of  tlie  convoluted  surface,  according  as  they  correspond  to  different 
containing  parts. 

The  first,  which  near  the  curvilinear  hollow,  is  slightly  convex  or 
rounded,  is  lodged  in  a considerable  cavity  of  tbe  cranium,  formed 
by  the  sphenoid  and  temporal  bones,  bounded  before  by  the  spheno- 
frontal arch,  and  behind  by  the  pyramid  or  petrous  portion  of  the 
temporal  bone.  This  part  of  the  convoluted  surface,  which  may  be 
named  the  spheno-temporal.,  is  one  of  considerable  importance,  and 
should  be  accurately  known  by  the  anatomical  student. 

The  posterior  division  of  this  region,  which  is  plane,  corresponds 
to  the  horizontal  or  cerebellic  part  of  the  hard  membrane,  and, 
though  not  to  be  distinguished  by  any  innate  or  organic  limit, 
may,  however,  for  the  sake  of  more  precision,  be  marked  by  this 
adventitious  character.*  It  may  be  named  the  cerebellic  region  of 
the  convoluted  surface. 

The  ordinary  appearance  of  the  convoluted  surface  is  well  known. 
It  is  formed  of  cerebral  matter,  of  a gray  or  dirty  wax  colour,  the 
surface  of  which  is  smooth  and  polished,  where  it  has  not  been  rent 
by  the  removal  of  the  membranes  and  their  attachments.  The  con- 
volutions consist  of  longitudinal  eminences,  rounded  transversely, 
running  in  various  directions,  and  separated  from  each  other  by 
deep  furrows.  If  these  be  examined  when  the  membranous  cover- 

* Lest  the  use  of  these  terms  be  objectionable  by  their  obscurity,  I may  observe 
that,  in  describing  parts  of  the  human  body,  it  is  not  unfi-equently  requisite  to  have 
recourse  not  only  to  marks  on  the  organ  described,  but  also  to  certain  characters  be- 
longing to  the  contiguous  parts.  The  first  of  these  may  be  named  the  orr/anic  or  inr 
note,  as  they  belong  to  the  organ  ; the  second,  which  do  not  belong  to  it,  should  be 
named  adventitious  or  esoteric.  Tliis  is  indispensable  in  relative  anatomy. 


BRAIN. 


233 


ings  are  removed,  they  are  observed  to  present  many  minute  orifi- 
ces, into  which  the  soft  membrane  (Xstt-j]  meninx  tenuis^  -pia 

mater,)  transmits  filamentous  bodies,  most  of  them  minute  blood- 
vessels. They  are  neither  arteries  nor  veins  exclusively,  but  seem 
to  consist  of  both. 

Neither  the  eminences,  nor  the  hollows  or  depressions,  are  uni- 
form in  number  or  distribution ; and  in  no  two  brains  is  it  possible 
to  trace  any  similarity  in  the  figure,  presence,  or  direction  of  these 
objects.  This  must  he  understood  of  the  whole  upper,  lateral,  and 
posterior  part  of  the  convoluted  surface,  and,  in  short,  all  its  divi- 
sions, unless  where  it  approaches  the  central  or  figurate  suriace. 
In  the  latter  situation,  this  want  of  uniformity  disappears;  and  a 
number  of  important  objects  are  presented  to  the  attention  of  the 
observer.  The  points  at  which  this  approach  of  the  two  surfaces 
takes  place,  are.  Is#,  Along  the  rectilinear  margin  of  the  coramu- 
tual  region,  where  it  is  contiguous  with  the  upper  surface  and  the 
posterior  end  of  the  middle  or  central  band  ; 2d,  From  the  last  of 
these  situations,  on  each  side  over  the  protuberance  and  cerebral 
limbs ; 3(f,  From  this  again  by  the  outer  margin  of  the  cerebral 
limbs,  to  the  curvilinear  hollow  and  along  its  course.  In  the  last 
of  these  situations  chiefly  the  convoluted  surface  becomes  important, 
and  exhibits  objects  which  distinguish  these  regions  fi'om  the  others. 

The  outer  surface  of  the  cerebellum,  or  small  brain,  differs  from 
that  of  the  brain  proper.  It  cannot  be  said  to  be  convoluted  ; for 
it  does  not  present  the  tortuous  eminences  and  furrows  which  con- 
stitute the  convolutions  of  this  part  of  the  organ.  But  the  cere- 
bral matter  of  which  it  consists,  is  disposed  in  the  manner  of  plates 
{laminoe)  or  leaves  {folia),  parallel  to  each  other,  or  at  least  con- 
centric, and  separated  by  parallel  or  concentric  furrows.  It  is 
scarcely  requisite  to  say,  that  this  definition  is  not  meant  to  imply, 
that  the  direction  of  all  these  objects  is  the  same  throughout  the 
whole  organ, — but  merely  that  the  cerebellic  plates,  of  which  cer- 
tain groups  consist,  observe  the  same  direction ; — and  that  any 
one  or  two  plates  or  leaves  have  several  of  the  contiguous  ones  pa- 
rallel or  concentric  with  them,  while  those  of  the  next  group,  though 
disposed  differently,  observe  the  same  direction  in  relation  to  each 
other.  By  this  peculiarity  the  various  regions  of  the  laminated  or 
foliated  surface  of  the  small  brain  may  be  distinguished.  The 
plates  of  the  hemispheres  are  curvilinear  and  concentric,  and  pur- 
sue in  various  regions  of  the  organ  certain  definite  directions ; 


234 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


those  in  the  middle  between  the  hemispheres  are  straight,  trans- 
verse, and  parallel ; and  at  one  spot  they  are  oblique  and  parallel. 
By  means  of  these  invariable  characters  of  the  cerehellic  plates,  the 
surface  of  the  organ  may  be  conveniently  distributed  into  several 
divisions. 

To  the  cerehellic  plates  or  their  peculiarities,  little  attention  was 
given  before  the  time  of  Vincenzio  Malacarne,  professor  of  surgery 
in  the  city  of  Acqui,  in  the  duchy  of  Montferrat.  This  learned 
person,  the  most  diligent  descriptive  anatomist  of  his  time,  pub- 
lished in  the  year  1780  three  treatises  on  the  Anatomy  of  the 
Brain  ;*  in  the  third  of  which  he  describes  with  much  precision  and 
minuteness,  the  anatomical  characters  of  the  outer  or  laminated 
surface  of  the  cerebellum.  Some  knowledge  of  his  distinctions, 
which  were  adopted  by  Beil,  is  requisite  to  comprehend  distinctly 
the  configuration  and  structure  of  this  part  of  the  organ. 

Commencing  with  the  well-known  division  of  the  whole  organ  in- 
to two  hemispheres,  Malacarne  remarks,  that,  if  the  whole  upper 
surface  of  the  organ  be  presented  to  the  eye,  the  outline  of  each  he- 
mispherical surface  is  found  to  describe  three-fourths  of  a circle ; 
and  as  these  circular  segments  mutually  meet  towards  the  mesial 
plane,  where  they  are  respectively  adapted  to  different  parts,  the 
mode  of  union  varies  according  to  the  figure  of  these  adjoining  ob- 
jects. Is^,  As  the  hemispherical  border  approaches  the  anterior 
part  of  the  organ,  it  is  found  to  be  suddenly  interrupted,  where  the 
cerehellic  branches  or  peduncles  {crura  cerebelli)  are  connected  with 
the  protuberance,  and,  pursuing  a retrograde  direction  on  each  side 
towards  the  mesial  plane,  forms  a species  of  re-entrant  curvature. 
The  hollow  thus  formed,  which  corresponds  to  the  lower  of  the  four 
eminences  on  the  upper  surface  of  the  protuberance  {corpora  quad- 
ricjemina.  Die  Vierhugel,)  is  named  by  Malacarne  the  semilunar 
curvature, — (der  halbmondfbrraide  Ausschnitt;  Reil.)  2c7,  Again, 
as  the  hemispherical  borders  approach  the  posterior  part  of  the 
small  brain,  advancing  nearer  to  the  mesial  plane,  they  proceed,  by 
an  acute  circular  turn,  almost  straight  backwards,  so  as  to  form,  at 
the  posterior  edge  of  the  organ,  a deep  rectangular  notch,  )__(  not 
unlike  the  figure  of  the  ancient  lyre.  This  posterior  hollow,  in 
which  is  lodged  the  cerehellic  vertical  portion  of  the  hard  mem- 
brane {falx  cerebelli^)  is  named  by  Malcarne  the  common  perpendi- 

* Encefalotomia  Nuova  Universale  di  Vincenzo  Malacarne,  Saluzzesc.  Torino, 
1780. 


BRAIN. 


235 


cular  fissure  (incui'vatura^  and  by  Reil,  to  whose  fancy  this  epithet 
seems  to  have  been  deficient  in  expression,  the  purse~lihe  fissure 
(Der  beutelfcirmige  Ausschnitt.)  Between  these  two  well-marked 
boundaries  the  cerebellic  plates,  of  which  the  hemispheres  consist, 
are  united  in  the  middle  by  a confused  interlacing  junction,  {un  in- 
treccio  confuso  ed  irregolare  di  sostanza,')  to  which  the  Italian  ana- 
tomist gives  the  name  of  suture  {ruffe,  raphe)  of  the  cerebellum. 
I find  that  the  careful  removal  of  the  soft  membrane,  {pia  mater ^ 
renders  this  more  distinct,  and  shows  the  mesial  termination  of  the 
hemispherical  plates.  On  the  surface,  a large  hollow  between  the 
hemispheres,  and  extending  backwards  fi’om  the  semilunar  to  the 
purse-like  fissure,  previously  called  by  Haller  {vallecula,)  the  little 
valley,  received  from  Malacarne  the  corresponding  term  {Valletta) 
in  his  own  language. 

The  divisions  of  the  cerebellic  surface  made  by  IMalacarne,  and 
adopted  by  Reil,  are  founded  entirely  on  the  groups  of  plates,  and 
the  comparative  depth  of  the  furrows  by  which  these  groups  are 
separated.  Groups  of  plates,  separated  by  the  deepest  furrows, 
are  named  lobes,  (Zo5z,  M.  Lappen,  R.);  and  those  separated  by 
furrows  of  less  depth  are  named  lobules,  {lobetti,  I\I.  Lappchen, 
R.)  In  some  situations  the  lobules  present  divisions  formed  by 
furrows  of  less  depth,  between  which  the  groups  of  plates  are  of 
greater  or  less  size.  To  such  clusters  IMalacarne  gives  the  name 
of  laminar  leaflets,  {foglietti  laminosi.)* 

Each  hemispherical  surface  consists  of  five  lobes.  1.  The  ante- 
rior-upper. 2.  The  posterior-upper.  3.  The  posterior-lower.  4. 
The  slender,  rarely  exceeding  three  lines  in  breadth.  5.  The  two- 
bellied  or  biventral.  The  two  first  belong  to  the  upper  or  flat 
hemispherical  surface ; the  three  latter  to  the  lower  or  convex  he- 
mispherical surface.  Besides  these,  a sixth  lobe  may  be  mentioned 
as  common  to  the  two  hemispheres.  It  is  situate  on  the  mesial 
plane  of  the  upper  surface,  between  the  anterior  end  of  the  middle 
line  {raffe,)  and  the  middle  or  apex  of  the  semilunar  fissure.  This 
situation  is  not  an  improper  reason  for  the  name  by  which  IMala- 
carne has  distinguished  it, — the  central  lobe. 

In  the  bottom  of  the  purse-like  notch  are  many  bundles  or 
clusters  of  plates,  which  unite  the  posterior  lobes  of  the  upper  and 
lower  surfaces  to  those  of  the  opposite  hemispheres.  These  IMa- 
lacarne names  transverse  laminar  chords  {cordoni  laminosi  traver- 
sali,)  or  commissures  of  the  cerebellum. 

* Encefalotomia,  nuova,  &c.  Parte  iii.  Articolo  i.  No.  13. 


236 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


The  anterior-upper  lobe,  with  four  sides  and  four  angles,  named 
therefore  by  Malacarne  the  quadrilateral  or  four-sided  lobe,  (vier- 
seitige^  Reil,)  approaches  somewhat  to  the  figure  of  the  trapezoid. 
It  is  bounded  by  three  curved  margins  and  one  straight  one.  Of 
the  former,  the  most  anterior  forms  one-half  of  the  semilunar  fis- 
sure ; while  the  posterior,  which  is  also  the  longest,  and  parallel  to 
this,  is  a curvilinear  or  circular  tract  (the  great  furrow,)  extending 
from  the  bottom  of  the  purse-like  fissure  behind  to  the  anterior 
outline  of  the  hemisphere  before,  where  it  terminates  about  one 
inch  from  the  end  of  the  semilunar  fissure.  This  last  space  be- 
tween the  anterior  end  of  the  great  furrow  forms  the  third  curved 
margin  of  the  four-sided  lobe ; while  its  straight  margin  is  made 
by  the  middle  line,  which  here  is  common  to  the  two  lobes.  Ma- 
lacarne further  divides  this  lobe  into  five  lobules,  and  describes  the 
limits  of  each  with  minuteness  and  accuracy.  For  the  details  of 
these  distinctions  1 refer  to  the  original. 

The  posterior-upper  lobe — the  second  division  of  the  upper  he- 
mispherical surface — may  be  defined  in  the  following  manner. 
The  circular  tract  or  great  furrow,  which  I have  already  said  forms 
the  posterior  margin  of  the  four-sided  lobe,  is  its  anterior  boun- 
dary. The  hemispherical  outline  of  the  upper  surface,  if  traced 
from  before  backwards,  will  be  found  to  coincide  about  1^  inch, 
sometimes  more,  from  the  purse-like  notch,  with  a considerable 
furrow  (the  hoi’izontal,)  which  turns  round  at  the  purse-like  notch 
to  meet  the  great  furrow  already  mentioned.  The  curved  outline 
thus  continued  is  the  outer  boundary  of  the  posterior  lobe  ; and  it 
is  easy  to  perceive,  that,  in  consequence  of  the  direction  which  this 
line  observes,  and  its  meeting  with  the  great  furrow,  the  lobe 
is  contained  between  the  horizontal  and  great  furrow,  or  between 
two  curved  lines.  This  lobe  is  subdivided  by  Malacarne  more  mi- 
nutely than  the  former.  It  is  found,  however,  that  the  number  of 
lobules  is  not  the  same  in  both, — those  of  the  left  being  most 
uniformly  about  eight,  while  those  of  the  right  are  more  numerous, 
but  in  general  less  distinctly  marked. 

These  with  the  central  lobe,  the  general  situation  of  which  has 
been  already  noticed,  form  the  several  divisions  of  the  uj)per  region 
of  the  cerebellic  laminated  surface.  The  inferior  region  presents 
divisions  more  numerous,  more  complicated,  and  more  interesting. 

The  first  of  these,  the  posterior-lower,  is  contiguous,  at  its  outer 
or  greater  boundary,  with  the  posterior-upper  lobe,  where  a small 


BRAIN. 


237 


segment  of  it  is  seen,  when  the  cerebellum  is  examined  from  above. 
Its  anterior  or  inner  boundary  is  marked  by  a curvilinear  furrow 
of  moderate  depth,  by  which  it  is  separated  from  the  slender  lobe, 
and  the  posterior  end  of  which  terminates,  not  in  the  purse-shaped 
notch,  but,  after  a sigmoid  turn  towards  the  laminar  pyramid,*  is 
insensibly  lost  among  a cluster  of  transverse  plates,  which  shall 
be  afterwards  noticed. 

Immediately  anterior  to  this  is  found  the  slender  lobe,  {il  lobo 
sottile,  Malacarne ; l)er  zarte  Lappen,  Reil ;)  which  is  not  above 
three  lines  broad,  and  being  contained  between  two  concentric  fur- 
rows, is  not  unlike  the  segment  intercepted  by  the  truncated  arcs  of 
two  small  circles  of  a sphere. 

The  space  of  the  hemispheric  surface  within  the  slender  lobe,  or 
between  this  and  the  peduncle  or  arm,  is  inclosed  by  three  circular 
lines,  two  of  which,  the  exterior  and  interior,  correspond  to  so  many 
furrows ; while  the  third,  which  is  anterior,  is  formed  by  the  hori- 
zontal or  marginal  furrow.  The  space  thus  inclosed  is  similar  to 
a spherical  triangle,  and  is  occupied  by  a group  of  plates  which 
Malacarne  denominates  the  biventral  lobe,  (der  Zwey-bauchige  Lap- 
pen,  Reil.)  Its  contiguity  with  the  cerebral  end  of  the  pneumo- 
gastric  nerve  led  Vicq-D’Azyr  to  give  it  the  name  of  the  lobule  of 
the  eighth  pair,  (lobule  du  nerf  vague ,-)  and  its  situation  at  the  pos- 
terior corner  of  the  peduncle,  and  under  that  body,  is  the  reason 
why  it  was  called  sub-peduncular  lobule  by  Dr  Gordon.  Of  these 
plates  the  arrangement  is  peculiar,  since  they  are  neither  so  ex- 
actly concentric  as  in  the  other  lobes ; nor  yet  is  their  direction 
different  from  each  other.  The  plates  at  its  outer  margin  are  the 
largest,  as  they  extend  the  whole  length  from  the  marginal  furrow 
to  the  end  of  the  slender  lobe,  at  which,  however,  they  are  con- 
tracted to  a narrow  point.  The  next  set  are  shorter,  and  are  more 
contracted  or  acuminated  at  their  posterior  end,  where  they  are 
contiguous  to  the  almonds  or  tonsils.  The  third  and  last  set  are 
the  shortest,  and  are  more  twisted  down,  as  it  were,  next  the  al- 
monds. These  contracted  or  acuminated  ends  of  the  cerebellic 
plates  are  named  (code,)  tails  by  Malacarne. 

The  disposition  now  described  renders  the  posterior  corner  of 
the  biventral  lobe  very  pointed,  and  its  margin  very  concave  ; and 
between  this  margin  and  the  parts  which  occupy  the  valley  is  placed 
a group  of  plates  somewhat  convex,  rounded,  and  disposed  also  in 

* Encefalotomia,  &c.,  Articolo  i.  No.  20,  ed  Articolo  ix.  No.  77.  See  p.  318. 


238 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


a peculiar  manner.  This  group  Malacarne  names  the  tonsil,  or 
tonsils,  {tonsille.,)*  a terra  which  Reil,  regarding  it  synonymous  with 
amygdalcE^  renders  literally  almonds,  (Die  Mandeln) ; the  spinal  lo- 
bule of  Dr  Gordon.  If  the  cerebellum  be  examined  before  the 
head  of  the  spinal  chord  is  cut  from  the  protuberance,  the  inner 
margin  of  the  almond  will  be  found  contiguous  to  the  oval  emi- 
nence {corpus  olivare,')  and  even  pressed  by  it.  It  is  best,  however, 
to  examine  the  almonds  after  the  chord  {medulla  oblongata')  has 
been  removed.  It  will  then  be  perceived  that  each  almond  is 
bounded  on  the  outside  by  a well-marked  circular  furrow,  which 
separates  it  from  the  biventral  lobe  on  the  inside  by  a free  surface 
directed  to  the  corresponding  surface  of  the  opposite  almond ; and 
before,  by  a continuation  of  this  directed  outwards  toward  the  bi- 
ventral lobe.  I have  already  said  that  the  direction  of  the  consti- 
tuent plates  of  this  body  is  peculiar.  In  general  they  observe  a 
direction  opposite  to  that  of  the  biventral  plates ; so  that,  if  pro- 
duced, they  would  cross.  Its  apex  or  most  pointed  corner  is  con- 
tiguous to  that  of  the  biventral  lobe ; and  altogether,  each  almond 
presents  the  appearance,  on  a cursory  glance,  of  two  similar  bodies 
directed  inversely  to  each  other. 

The  last  body  which  I shall  notice  here  is  the  Flock  or  Flocks. 
The  description  of  its  situation,  as  given  by  Malacarne,  is  by  no 
means  clear ; but  perusal  of  the  context,  with  examination  of  the 
parts  described,  can  leave  no  doubt  on  the  certainty  of  the  object 
which  he  has  in  view.  The  flock  {il fioccho,  il Jiocchi,  Die  Flocken,) 
is  a minute  body,  of  a shape  not  easily  defined,  situate  in  the  an- 
gular hollow  between  the  biventral  lobe  and  the  branch  or  peduncle 
{crus ; gamba  ; braccia ; Die  Arme)  of  the  small  brain.  The  lower 
or  free  surface  of  the  latter  object  (tbe  branch)  possesses  an  ante- 
rior and  posterior  margin  or  corner.  The  latter  is  contiguous  to 
the  biventral  lobe,  from  which  it  is  separated  by  a small  furrow, 
out  of  which  the  flock  seems  to  issue.  Each  flock  consists  of  six 
or  seven  plates  {laminee)  starting  directly,  as  it  were,  from  the  be- 
ginning of  the  peduncle,  and  with  the  concave  margins  directed 
towards  the  protuberance. 

Ruysch  has  represented  in  their  site  objects  to  which  he  applies 
the  name  of  vermiform  prominences ; a circumstance  which  is  in 
some  measure  to  be  ascribed  to  the  vague  manner  in  which  this 
term  has  been  used. 


Encefalotomia,  Articolo  ix. 


BRAIN. 


239 


The  valley,  (vallecula,  Valletta,  das  Thai)  or  hollow  between  the 
two  hemispheres,  is  occupied  by  a numerous  series  of  plates,  which 
lie  transversely,  are  parallel  to  each  other,  and  which  form  a sort 
of  uniting  medium  of  the  cerebellic  plates  of  each  side.  The  ap- 
pearance of  this  region  in  the  brain  of  the  dog  and  monkey,  the 
animals  which  the  ancient  anatomists  chiefly  dissected,  might  fur- 
nish them  with  some  reason  for  applying  to  it  the  name  of  worm, 
or  worm-shaped  body  ; (<rxwX'/)g,  exoAn^osidyis.)  But  the  mo- 

dern anatomists  are  not  bound  to  apply  it  to  the  corresponding 
part  of  the  human  cerebellum,  which  certainly  by  no  means  jus- 
tifies the  appellation.  The  confusion  which  has  arisen  from  this 
practice  of  imitating  the  ancients  is  a sufficient  reason  to  abandon 
the  term  for  ever ; since  scarcely  two  anatomists  agree  in  giving 
the  name  of  vermiform  process  to  the  same  part  of  the  organ. 

With  a view  to  obviate  all  misconception  on  this  point,  Mala- 
carne  has  recourse  to  distinctions  completely  new.  Beginning  with 
the  back  end  of  the  valley  at  the  purse-shaped  notch,  where  are 
seen  the  plates  afterwards  named  by  Reil  the  short  exposed  cross- 
bands^  (Die  kurzen  und  sichtbaren-Querbander ;)  and  the  long  co- 
vered cross-bands,  (Die  langen  verdeckten  Querbander ;)  and  pro- 
ceeding forward,  he  distinguishes  a group  of  parallel  plates,  or  la- 
minated leaves,  to  which  he  applies  the  name  of  pyramid.  This 
body,  which  is  bounded  behind  by  the  purse-shaped  notch,  and  be- 
fore by  another  cluster  of  plates  called  by  Malacarne  the  uvula, 
consists  of  twenty  parallel  plates,  of  which  six,  he  observes,  are  very 
short ; and  a triangular  termination  in  the  longer,  forms  the  sum- 
mit of  the  body.  The  uvula  (ugola)  (Der  Zapfen,*  Beil,)  which 
is  anterior,  he  found  to  consist  of  twelve  laminated  leaves,  to  have 
six  lines  of  longitudinal  extent,  and  four  of  breadth.  It  is  smaller 
than  the  pyramid,  and  conical,  with  its  base  turned  to  that  body, 
(Reil).  Lastly,  anterior  to  the  uvula,  and  separated  from  it  by  a 
furrow,  is  the  laminar  tubercle,f  (tuberculo  laminoso,)  consisting  of 
about  ten  thin  leaves  or  transverse  plates.  This  body,  which  is  the 
smallest  in  the  row,  is  the  nodule  or  knot,  (Das  Knotchen)  of  Reil. 

The  second  surface  of  the  brain  is  very  different  from  the  first. 
In  situation  it  is  interior  or  central ; and  its  configuration  is  such, 

* Mr  Mavo,  by  translating  this  term  spigot,  makes  it  appear  to  be  a different  part 
from  that  meant  by  Malacarne,  and  understood  by  Reil.  Though  the  word  der  Zapfen 
signifies  spigot,  it  is  also  used  to  denote  the  uvula,  and  in  this  sense  it  is  employed  by 
Reil. 

t Encefalotomia  Nuova,  &c.  Parte  iii.  Articolo  x.  p.  61. 


240 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


that  it  may  be  named  the  jigurate  or  symmetrical  surface  of  the 
brain.  Instead  of  presenting  the  uniform  eminences  and  hollows 
which  distinguish  the  convoluted  sirrface,  it  is  disposed  or  moulded 
into  definite  shapes,  which  correspond  with  each  other,  as  they  are 
situate  on  opposite  sides  of  the  middle  plane, — or  the  parts  of  which, 
when  situate  on  this  plane,  are  exactly  symmetrical.  The  surface 
formed  by  these  variously  figured  objects,  bounds  what  are  termed 
in  the  common  descriptions  the  ventricles  or  cavities  of  the  brain. 
They  cannot  justly  be  termed  cavities  any  more  than  the  hollows 
between  the  convolutions,  but  ought  to  be  viewed  as  continuations 
of  the  exterior  or  convoluted  surface.  As  the  several  objects  of 
the  figurate  surface  are  well  known,  I shall  at  present,  avoiding 
minute  description,  notice  those  circumstances  only  which  have  not 
been  sufficiently  studied,  or  correctly  represented,  or  which  are 
necessary  to  establish  the  general  principle, — that  the  convoluted 
surface  of  the  brain  and  the  laminated  surfaee  of  the  cerebellum 
communicate  directly  with  the  inner,  central,  or  figurate  surface  of 
these  organs. 

The  commutual  or  dichotomous  region  of  the  convoluted  surface 
is  terminated  below  by  a sinuosity,  which  is  formed  chiefly  by  a 
part  of  the  brain,  remarkable  in  appearance  and  organization.  This, 
which  was  named  by  the  ancient  anatomists  the  smooth  or  polished 
body  (<rw,t(.a  nXXosIdi:,  corpus  lcBve)f  to  distinguish  it  from  those  sur- 
faces which  were  formed  by  a cutting  instrument,  appears  in  the 
form  of  white  fibrous  matter,  passing  transversely  between  the  he- 
mispheres ; but  is  also  marked  by  certain  longitudinal  lines,  fii’st 
correctly  represented  by  Vicq-DAzyr.  The  most  conspicuous  of 
these  is  that  which  lies  exactly  in  the  middle  plane,  and  which  is 
formed  by  the  meeting  of  the  transverse  fibres,  of  which  this  body, 
termed  middle  or  central  hand^  {rnesolobe  of  Chaussier,  the  beam 
(der  Balken)  of  Reil,)t  consists.  These  fibres,  which  issue  like 

* This  is  the  literal  translation  and  the  true  meaning  of  the  term  used  by  the  Alex- 
andrian school.  The  name  corpus  callosum,  which  is  adopted  by  modern  anatomists, 
is  a bad  ti'anslation  made  at  the  revival  of  literatoe.  In  defence  of  the  error,  Vicq- 
D’Azyr  contradicts  nature  by  the  assertion,  that  this  is  somewhat  harder  or  firmer  than 
the  other  parts  of  the  brain.  “ Cette  production  a plus  de  co7isistence  que  le  reste  du 
cerveau. — Ce  corps  un  peu  plus  dur  que  le  reste  de  la  substance  blanche  du  cerv'eau.  ” 
Of  many  brains  examined,  with  a different  object,  certainly,  from  that  of  proving  the 
learning  or  ignorance  of  the  translators  of  the  Greek  physicians,  I never  could  perceive 
any  difference  in  the  consistence  of  this  and  other  parts  of  the  brain. 

f Archiv.  fiir  die  Pliysiologie.  Neunter  Band,  Erstes  Heft.  3.  b.  p.  172. 


BRAIN. 


241 


white  parallel  lines,  exceedingly  minute,  from  the  substance  of  the 
hemispheres,  either  stop  suddenly,  or  change  their  direction  at  this 
point.  Their  sudden  termination  gives  rise  to  an  appearance,  to 
which  the  expressive  but  erring  epithet  of  suture  (raphe)  has  been 
given.  On  each  side  of  this  other  lines  are  remarked  following 
the  same  direction.  In  general,  they  are  situate  about  three  or 
four  lines  from  the  median  plane ; but  are  in  a few  instances  ob- 
served to  be  very  regular  in  their  disposition  at  the  anterior  end  of 
the  middle  band.  About  its  middle,  however,  a very  distinct  ap- 
pearance of  lines  collected  into  a considerable  bundle,  may  be 
observed  proceeding  backwards  to  its  posterior  end.  As  they  ad- 
vance they  become  more  distinct,  are  about  1^  line  broad,  and  of 
a grayish  colour ; at  the  posterior  end  of  the  middle  band,  they 
diverge  somewhat,  and,  passing  over  this,  proceed  in  a lateral  di- 
rection downwards,  till  they  are  lost  about  the  spot  where  the  limbs 
of  the  brain  (crura  cerebri^  Die  Hirnschenkel)  issue  from  the  optic 
eminences.  This  forms  the  inner,  central,  or  gray  portion  of  the 
cylindroid  eminence. 

The  posterior  extremity  of  this  body  is  rounded ; and  when  the 
membranes  have  been  removed,  the  surface  which  forms  this  round- 
ed end  is  found  to  communicate  directly  with  the  chamber  named 
third  or  middle  ventricle.  This  surface  is  in  truth  continued  for- 
ward, and  forms  the  vault  or  ceiling,  (fornix,  Die  Zwillingsbinde, 
the  twain  band,  Reil,)  a point  which,  though  sufficiently  obvious,  is 
never  noticed  in  description,  or  perspicuously  demonstrated.  The 
names  of  callous  body  and  vault  are  applied  in  the  ordinary  works, 
as  if  they  were  denominations  of  different  objects,  or  rather  of  dif- 
ferent bodies.  If  they  are  still  to  be  retained,  it  ought  to  be  stated 
that  they  are  names  applied  to  opposite  surfaces  only  of  the  same 
object. 

The  relations  of  the  round  or  posterior  end  of  the  middle  band 
are  w'orthy  of  examination.  The  handle  of  a scalpel  inserted  be- 
neath it  will  be  found  to  be  in  the  middle  ventricle,  with  the  vault 
above,  the  conarium  or  pineal  body,  and  four  eminences  of  the  up- 
per surface  of  the  protuberance  (corpora  quadrigemina)  below,  and 
a part  of  each  optic  chamber  on  each  side.  I find  it  convenient  to 
remove  the  posterior  part  of  the  hemispheres  by  a transverse  sec- 
tion following  the  plane  or  level  of  the  hinder  end  of  the  central 
band.  A distinct  view  is  thus  given  of  this  communication  of  the 
convoluted  with  the  figurate  surface  ; and  it  may  be  observed,  not 

Q 


242 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


only  in  the  middle,  but  on  each  side.  The  middle  one  is  bounded 
above  by  the  posterior  end  of  the  middle  band  and  the  back  part 
of  the  vault ; below,  by  the  pineal  body  and  the  four  eminences ; 
before,  it  is  continuous  with  the  middle  ventricle ; behind,  it  looks 
to  that  space  between  the  convoluted  surface  of  the  brain  and  the 
laminated  surface  of  the  cerebellum,  which  is  occupied  by  the  hori- 
zontal part,  (tentorium  cerebelli),  of  the  hard  membrane. 

On  the  sides, — that  is  beyond  the  margin  of  the  body  with  the 
four  eminences,  a different  arrangement  is  observed.  The  poste- 
rior end  of  the  middle  hand  penetrates  into  the  substance  of  the 
hemispheres ; but  the  gray  chords  which  have  been  already  noticed, 
in  pursuing  their  lateral  course,  are  immediately  enveloped  in  white 
plates,  derived,  as  we  shall  see,  from  the  sides  of  the  vault,  assum- 
ing thus  a cylindrical  appearance.  Thus  is  formed  exactly  oppo- 
site to  the  cerebral  limbs,  a body  with  a free  rounded  surface,  which 
bends  in  a curvilinear  direction  laterally  and  downwards,  and  is 
found  to  be  the  great  hippocampus  or  cylindroid  process.  (Chaus- 
sier.)  In  observing  this  curvilinear  course,  it  rests  on  and  corre- 
sponds to,  the  upper  margin  of  the  cerebral  limb,  as  it  issues  from 
the  optic  chamber.  It  must  not,  however,  be  imagined  that  it  ad- 
heres to  this  body.  The  surfaces  both  of  the  beginning  or  upper 
end  of  hippocampus,  and  of  the  cerebral  limb,  are  free  and  uncon- 
nected. They  are  indeed  covered  wdth  vascular  membrane,  (pia 
mater,)  which  keeps  them  in  apposition ; but  if  this  be  removed,  as 
it  ought  alw'ays  to  be,  the  two  surfaces  will  he  found  quite  distinct, 
and  in  no  manner  connected,  unless  in  corresponding  wdth  each 
other.  The  whole  of  this  communication  may  be  seen,  and  is  best 
examined  by  keeping  the  organ  in  its  natural  position,  and  view- 
ing it  from  behind,  after  the  posterior  parts  of  the  cerebral  hemi- 
spheres have  been  removed.  It  forms  what  was  described  by  Bichat 
under  the  name  of  the  great  cerebral  fissure*  This  denomination 
does  not  accurately  express  the  idea  intended ; nor  does  the  idea 
itself,  it  may  be  remarked,  present  a correct  view  of  the  natural 
arrangement.  The  conformation  which  I have  attempted  to  de- 
scribe does  not  form  a fissure,  but  a regular  symmetrical  opening, 
by  which  the  convoluted  surface  communicates  distinctly  and  di- 
rectly with  that  which  is  figurate. 

The  next  step  of  the  process  in  the  further  exposition  of  this 
opening  or  communication,  requires  the  inversion  of  the  brain,  and 

* Anat.  Descriptive,  Tom.  III. 


BRAIN. 


243 


the  exposition  of  the  inferior  regions  of  the  convoluted  surface, — the 
base  of  the  brain.  We  have  seen  the  manner  in  which  the  convo- 
luted passes  into  the  figurate  surface,  above  and  behind  the  middle 
band.  At  the  inferior  regions  this  transition  is  effected  in  a mode 
somewhat  different; — and  the  channel  or  means  by  which  it  is 
made,  is  the  curvilinear  hollow.  To  understand  clearly  the  rela- 
tions by  which  this  is  established,  the  demonstrator  should  remove 
in  small  portions  the  membrane  which  covers  the  optic  commissure 
and  tracts,  the  pituitary  peduncle,  the  pisiform  eminences,  and 
which  binds  together  the  adjoining  convolutions,  and  especially 
those  which  are  connected  by  it  to  the  limbs  of  the  brain.*  When 
the  convolutions  are  thus  exposed,  the  furrows  on  each  side  of  the 
hollow  will  be  found  to  be  very  deep,  and  the  eminences  propor- 
tionally high  from  the  more  solid  part  of  the  encephalic  organ  ; 
and  the  hollow  itself  will  appear  almost  like  the  furrow  of  a con- 
volution on  a large  scale.  Its  peculiarity  indeed  is,  that  the  bot- 
tom of  the  hollow  is  not  convoluted,  but  presents  an  extensive  uni- 
form space  of  grayish  cerebral  matter,  on  each  side  of  wliich,  but 
especially  behind,  the  convolutions  are  very  large  and  distinct. 
This  convoluted  part  begins  insensibly  at  the  outer  or  lateral  edge 
of  the  hemisphere,  where  it  is  narrow  ; becomes  broader  as  it  ad- 
vances forwards  and  inwards  ; and  about  one  inch  from  the  mesial 
plane,  is  particularly  distinct,  broader,  and  more  spacious  than  at 
any  other  part  of  its  course. 

It  here  presents  an  infinity  of  holes  or  orifices  of  various  size  in 
the  cerebral  substance,  not  arranged  in  any  regular  order,  but  uni- 
formly found  in  this  situation.  Some  of  these  orifices  are  suffi- 
ciently large  to  admit  the  point  of  a small  silver  probe ; but  the 
greater  number  are  more  minute,  and  do  not  exceed  the  calibre  of 
a common-sized  bristle.  The  space  over  which  they  extend  is  va- 
rious, and  its  figure  cannot  be  accurately  denned  ; it  is  generally 
equivalent  to  the  half  of  a square  inch.  In  numerous  dissections, 
I have  found  it  uniformly  at  this  part,  and  of  this  size,  as  nearly 
as  it  is  possible  to  estimate,  in  measurement  of  objects  so  variable 
as  those  of  the  organs  of  the  animal  body.  I have  not  been  able 
to  recognize  any  difference  in  the  colour  of  this  and  other  parts  of 
the  convoluted  surface.  I suspect,  therefore,  that  Vicq-D’Azyr, 

* This  process  is  best  performed  by  the  scissors  and  forceps,  ^rith  the  occasional 
use  only  of  the  scalpel,  and  with  the  aid  of  an  assistant  with  delicate  fingers  and  for- 
ceps. 


244 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


who  in  noticing  this  part  has  called  it  the  white  perforated  substance, 
{substance  blanche  perforce),  applied  the  term  of  colour  without  ex- 
amining the  contiguous  parts,  when  denuded  of  their  membranous 
investments.  The  same  name  nearly,  {lamina  perforata),  has  been 
given  it  by  Reil.  The  orifices  which  characterize  this  part  of  the 
brain  admit,  from  the  Sylvian  or  middle  artery,  an  infinity  of  blood- 
vessels, which  here  penetrate  the  part  denominated  the  hook-shaped 
cerebral  band  (Der  Haaken-fbrinige  Mark-bundcl)  delineated  by 
Reil.  This  circumstance  renders  the  adjoining  part  the  most  vas- 
cular of  the  whole  organ, — a fact  which  will  be  shown  to  be  im- 
portant in  the  pathology  of  the  brain. 

Anterior  to  the  perforated  spot  at  the  extreme  verge  of  the  un- 
convoluted  substance,  is  situate  a small  pointed  eminence,  of  gray 
colour,  shaped  like  a triangular  pyramid,  most  conspicuous  when 
cleared  of  the  membrane  which  covers  it.  Proceeding  backward 
from  this,  we  remark  two  slender  white  lines  of  different  lengths, 
and  following  different  directions.  The  inner  of  these  is  short ; 
and  after  a course  seldom  exceeding  four  or  five  lines  in  the  adult 
brain  suddenly  ceases  to  be  visible.  The  outer  one  is  much  longer, 
follows  a curved  direction,  with  the  concave  part  of  its  course  di- 
rected anteriorly,  and  is  of  a more  vivid  white  colour.  These  two 
lines  are  the  generating  or  initial  filaments  of  the  first  pair  of  nerves. 

Within  the  perforated  spot  the  curvilinear  hollow  is  generally 
conceived  to  be  terminated.  The  unconvoluted  space,  however,  in 
which  it  consists,  is  here  directly  continuous  with  the  figurate  sur- 
face of  the  brain.  This  space  indeed  makes  here  a sharp  turn 
backwards ; and  having  on  the  inside  the  long  cerebral  band 
termed  the  optic  tract,  may  be  conceived  to  be  bounded  by  the 
limb  of  the  brain.  This  body,  with  that  of  the  opposite  side,  will 
be  imperfectly  seen  at  first ; and  though  the  end  which  unites  each 
with  the  bridge  or  protuberance  is  sufficiently  conspicuous,  the  op- 
posite extremity  cannot  be  distinctly  perceived.  It  is  indeed  co- 
vered by  a portion  of  the  convoluted  surface,  the  inner  and  promi- 
nent surface  of  the  medio-inferior  or  spheno-temporal  region.  This 
must  therefore  be  gently  moved  outwards  or  laterally,  and  also 
raised ; and  with  the  aid  of  the  handle  of  a scalpel  and  the  fingers 
of  a dexterous  assistant,  the  cerebral  limb  may  be  shown  to  be  here 
crossed  or  surrounded  by  the  optic  tract  of  the  side.  The  purpose 
of  this  part  of  the  exposition  is  to  show  the  geniculate  bodies,  or 

posterior  eminences  of  the  optic  chambers. 

4 


BRAIN. 


245 


But  the  attention  of  the  demonstrator  is  to  be  directed  to  that 
part  of  the  convoluted  surface  which  covers  the  anterior  end  and 
outer  margin  of  the  cerebral  limb,  and  which  has  been  raised  on 
the  scalpel-handle.  When  gently  everted,  it  is  found  to  present 
the  thin  white  body  named  the  tape  or  fringe  {tcBuia')  of  the  hippo- 
campus ; and  if  the  portion  of  convoluted  brain  most  anterior  or 
next  to  the  curvilinear  hollow  be  raised  and  everted  in  the  same 
manner,  the  anterior  end  of  this  object  termed  the  foot  {pes  hippo- 
campi) will  come  into  view.  If  this  operation  be  properly  per- 
formed, no  part  will  be  torn,  broken,  or  displaced ; the  objects  ex- 
hibited are  free  surfaces,  not  adhering  to  each  other  but  only  in 
apposition.  The  white  plate  or  tape  of  the  hippocampus  forms,  in 
the  natural  position  of  the  organ,  the  outer  and  lower  border  of  the 
opening,  while  the  limb  of  the  brain,  and  after  that  the  outer  and 
lower  surface  of  the  optic  chamber,  forms  its  inner  border. 

To  obtain  an  idea  yet  more  clear  and  distinct  of  this  communi- 
cation between  the  convoluted  and  figurate  surfaces  of  the  brain,  it 
is  convenient  to  follow  the  direction  of  the  opening  with  the  scalpel 
handle  backwards  and  upwards,  until  it  reach  the  upper  margin  of 
the  brain-limb,  where  it  is  shown  to  be  merely  a continuation  of 
the  lateral  part  of  the  posterior  opening.  This  step  of  the  exposi- 
tion requires  cautious  and  gentle  management ; and  the  peculiar 
curvature  which  the  parts  forming  the  outer  border  of  the  commu- 
nication follow,  renders  it  difficult  to  avoid  laceration  or  displace- 
ment. In  general,  it  is  best  accomplished  on  a single  hemisphere, 
from  which  the  cerebellum  has  been  previously  removed ; but  it  is 
desirable  to  preserve  also  the  whole  of  the  central  band,  which  shows 
not  only  the  relative  connection  of  the  several  parts,  but  serves  also 
to  demonstrate  a curious  fact  in  the  configuration  of  the  parts  form- 
ing the  outer  border  of  the  communication.  This  is  the  hippo- 
campus through  its  entire  course,  or  the  body  which  its  figure  has 
led  Professor  Chaussier  to  name  the  cylindroid  process. 

This  body  consists  essentially  of  two  parts.  The  first  is  an  inner 
or  central  portion,  gray  in  colour,  notched  or  indented  in  appear- 
ance, and  though  free  at  the  indented  edge,  adhering  to  the  cere- 
bral substance  by  its  opposite  margin.  This  is  the  gray  indented 
band;  (Gordon  ;) — le  corps  godronnee,  Vicq-D’Azyr.)  It  is  as 
thick  as  a large  crow-quill.  This  is  covered  by  the  outer  or  second 
part,  which  is  a broad  thin  plate  of  white  cerebral  matter  rolled  or 
folded  over  the  gray  indented  band,  precisely  as  a map  is  rolled 


246 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


rover  a cylinder  of  wood,  and  covering  it  unless  removed  by  art. 
This  last  part  of  the  cylindroid  process  is  what  is  well  known,  and 
always  described  under  the  name  of  the  tape  or  fillet  of  the  hippo- 
campus. Its  ari-angement  with  regard  to  the  gray  indented  band 
is  less  generally  understood,  and  is  indeed  never  noticed  in  the  or- 
dinary descriptions.  A correct  idea  of  it  may  be  formed  in  the 
following  manner. 

Divide,  by  successive  transverse  sections,  the  hippocampus  from 
the  part  named  the  foot  upwards,  as  far  as  it  can  be  traced.  It  will 
be  found  that  each  section  presents  a central  portion  of  gray  matter, 
enveloped  in  a thin  curled  plate  of  white  matter,  which  is  free  at 
one  edge, — the  concave  one, — and  hangs  over  the  gray  band  like 
a veil,  but  adheres,  by  its  opposite,  to  the  cerebral  substance.  It 
will  be  perceived,  also,  that  the  white  plate  does  not  adhere  to  the 
gray  band,  unless  at  its  fixed  margin,  and  that  a probe  or  scalpel 
handle  may  be  introduced  into  the  angular  furrow  between  them.* 
As  the  sections  approach  the  upper  end  of  the  cylindroid  process  a 
new  arrangement  is  observed.  The  white  plate  becomes  unusually 
broad,  and  is  less  bent  or  rolled  over  the  gray  band ; while  the 
latter,  thus  less  completely  covered,  instead  of  following  the  same 
direction  with  the  white  plate  which  it  does  below,  is  much  sepa- 
rated from  it,  and  leaves  a considerable  angle  between  the  plate  and 
itself.  This  arrangement  is  most  conspicuous  where  the  process 
corresponds  to  the  upper  part  of  the  optic  chamber  and  the  cere- 
bral limb.  The  white  plate  of  the  hippocampus  traced  further  is 
found  to  coalesce  with  the  margins  of  the  vault,  and  tapering  as  it 
approaches  the  anterior  end  of  that  body,  is  finally  identified  with 
its  substance.  The  upper  termination  or  connection  of  the  gray 
band  is  different.  When  it  begins  to  recede  from  the  white  plate, 
which  it  does  nearly  opposite  to  the  optic  eminence,  it  proceeds  di- 
rectly to  the  rounded  posterior  end  of  the  central  band,  (corpus 
callosum,)  over  which,  and  along  the  upper  surface  about  one  inch, 
it  may  be  traced ; and  beyond  this  it  is  seldom  capable  of  being 
distinguished  from  the  white  matter  of  which  the  central  band  con- 
sists.f  The  gray  indented  hand,  therefore,  which  forms  the  inner 

* This  last  fact  may  also  be  demonstrated  without  transverse  sections,  by  simple 
elevation  of  the  white  plate  by  the  handle  of  the  instrument. 

-I  The  importance  of  this  object  in  forming  the  outer  border  of  the  great  commu- 
nication, will  rerrder  it  not  im2:iroper  to  glance  at  the  history  of  its  discovery.  Vicq- 
D’Azyr  is  supiJosed  to  have  been  the  first  anatomist  who  observed  and  described  its 
site  and  appearance  with  accuracy  ; and  we  find  him,  in  a Memoir  of  the  Royal  Aca- 


BRAIjS'. 


247 


or  central  part  of  the  cylindroid  process,  is  continuous,  or  connect- 
ed with  the  upper  surface  of  the  central  band  of  the  organ ; and 
if  the  terms  of  origin  or  derivation  be  admitted,  may  be  said  to  be 
derived  from  it ; while  the  thin  white  plate  which  is  rolled  over  the 
gray  band,  and  gives  the  hippocampus  its  cylindrical  figure,  is  con- 
nected with  the  under  surface  of  the  same  central  band,  or  that 
part  which  the  usual  nomenclature  styles  the  vault  {fornix)  of  the 
brain. 

Such,  as  nearly  as  language  can  represent,  is  the  configuration 
of  the  cylindroid  process, — an  object  which  it  is  impossible  to  know 
too  accurately,  if  we  reflect,  that  it  forms  the  entire  outer  border 
of  the  great  communication  between  the  convoluted  and  figurate 
surfaces  of  the  brain.  If,  by  the  method  now  described,  a clear 
idea  of  this  disposition  is  not  communicated,  it  is  expedient  to  use 
another  contrivance,  which  I have  rarely  found  to  fail  in  demon- 
strating the  facts  which  I wish  to  impress.  Let  a brain,  divested 
of  its  membranes,  be  inverted  ; and  when  the  opening  behind  the 
outer  margin  of  the  cerebral  limbs  has  been  exposed,  let  a deep 
transverse  incision  between  the  feet  of  the  hippocampus  of  each  side 
be  made.  This  incision  must  not  touch  the  cylindroid  process,  but 
going  deep  into  the  substance  of  the  organ,  will  detach  the  whole 
of  that  part  which  contains  the  several  objects  of  the  figurate  sur- 
face from  the  anterior  part  of  the  hemispheres.  The  portion  thus 
separated  will,  however,  still  adhere  by  the  sides  to  the  substance 
of  the  hemispheres ; and  other  incisions  must  be  made,  following 
the  direction  of  the  outer  or  lateral  margin  of  the  striated  bodies 


demy  of  Sciences  in  1787,  detailing  its  peculiarities  with  some  minuteness,  under  the 
name  of  “ Bord  externe  et  dentele  de  la  Come  d’Ammon.”  He  subsequently  repre- 
sented it  in  his  great  work  in  the  year  1786,  imder  the  name  of  gray,  cortical,  external 
notched  portion  of  the  Horn  of  Ammon,  and  speaks  of  it  familiarly  enough  by  the 
term  of  corps  godromiee.  Bichat,  however,  whose  descriptive  anatomy  was  pubhshed 
in  1802,  though  his  accurate  manner  prevented  him  from  overlooking  it,  and 
led  him  to  give  a sufficiently  minute  acco\mt  of  it,  boldly  asserted,  that  it  had 
been  entirely  neglected  by  authors.  Dr  Gordon  of  this  place,  who  was  quite  aware  of 
this  oversight  in  Bichat,  took  special  care,  in  demonstrating  it,  to  notice  the  merit  of 
Vicq-D’Az}T  ; and  this  fact  he  mentions  shortly  in  a note,  in  his  description  of 
the  gray  band.  None  of  these  eminent  anatomists  have  been  altogether  right  in  this 
matter  ; and  the  truth  is,  that  Vicq-D’Az}’r  is  not  the  first  who  dehneated  this  bodv. 
The  gray  indented  band  is  distinctly  represented  by  Pierre  Tarin,  in  the  second  en- 
graving of  his  Adversaria  ; and  although  this  had  been  pubhshed  in  1750,  tliirty  years 
before  the  engravings  of  Vicq-D’Azyr,  yet  it  was  requisite  for  the  latter  writer  to  make 
it  the  subject  of  a particular  memoir,  and  Bichat  to  wite  a description  of  it,  before  it 
seems  to  have  been  known  as  part  of  the  organ. 


248 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


(corpora  striata')  and  the  optic  chambers  (thalami  optici,)  until  the 
whole  be  completely  insulated.  If  these  incisions  be  properly  ma- 
naged, the  whole  of  the  middle  band,  the  vault,  the  cylindroid  pro- 
cess, and  the  white  tape,  will  be  left  uninjured,  and  will  present  a 
large  hollow  surrounded  by  an  extensive  border,  the  posterior  part 
of  which  is  made  by  the  posterior  end  of  the  central  band,  while  la- 
teral divisions  are  formed  by  the  cylindroid  process  of  either  side. 
The  observer  will  likewise  form  a very  just  idea  of  the  situation 
and  connections  of  the  middle  band,  and  will  perceive  that  its  infe- 
rior surface  is  the  same  as  that  named  vault  or  ceiling.  He  will 
further  remark,  that  the  thin  white  plates  (tcBnice)  which  are  attach- 
ed to  the  margins  of  this  object,  and  between  which  is  the  space 
improperly  named  the  extend  in  a circular  and  revolute  di- 
rection outwards  and  downwards,  so  as  to  cover,  in  the  mode  de- 
scribed, the  gray  hand  of  the  cylinder,  and  give  this  object  its  cy- 
lindrical aspect. 

The  correct  understanding  of  the  outer  border  of  this  commu- 
nication should  be  followed  by  an  equally  just  idea  of  those  parts 
which  form  what  we  must  name  its  inner  border.  These  are  more 
numerous  and  rather  more  complicated ; but  frequent  examination, 
with  a little  attention,  will  enable  the  student  to  overcome  all  the 
difficnlties  with  which  they  may  be  attended.  The  parts  contained 
in  the  mass  of  brain  removed,  as  we  described  in  the  last  section, 
will  contribute  also  very  much  to  render  the  knowledge  of  this 
border  easy  and  intelligible.  I have  already  said,  that  at  the 
posterior  end  of  the  middle  hand  the  inner  or  lower  border  is 
formed  by  the  four  eminences  (c.  quadrigemina)  situate  on  the 
upper  surface  of  the  thick  mass  named  protuberance.  On  each 
side  of  these  the  inner  border  is  formed  by  successive  portions  of 
the  optic  chamber,  until  it  has  reached  the  inferior  region  of  this 
body,  where  the  outer  and  lower  margin  of  the  limb  of  the  brain 
becomes  the  border  of  the  opening.  To  render  this  arrangement 
more  intelligible,  I shall  here  state  some  circumstances  of  the  fi- 
gurate  surface,  which  are  either  omitted  or  indistinctly  mentioned 
in  the  ordinary  descriptions. 

Its  principal  objects  are  familiarly  known ; and  none  can  be  igno- 
rant of  the  situation  of  the  striated  bodies,  the  optic  chamber,  the 
semicircular  chord  between  them,  and  other  similar  objects. 

The  posterior  eminences,  or  the  optic  chambers,  hold  the  most 


BRAIN. 


249 


important  place ; and  their  connection  and  relative  situation  render 
them  much  more  interesting,  than  they  are  usually  made  in  works 
of  descriptive  anatomy.  Connected  before  and  on  the  outside  to 
the  striated  body  by  means  of  the  double  semicircular  chord  {cen- 
trum semidrculare  geminum,  Vieussens,)  each  optic  eminence  pre- 
sents four  free  surfaces, — the  upper,  the  inner,  the  posterior,  and 
the  lower.  The  upper,  the  first,  is  gently  rounded  and  of  white 
colour.  Its  figure  and  limits  are  not  easily  defined.  The  outer 
margin  is  bounded  by  the  circular  band,  which  even  passes  on  an- 
terior to  it,  so  as  to  form  its  boundary  in  that  direction  also.  Be- 
hind, it  is  less  distinctly  limited,  unless  by  the  appearance  of  a con- 
siderable prominence,  which  has  been  generally  named  the  posterior 
tubercle  of  the  optic  couch.  The  inner  margin  of  the  upper  sur- 
face is  most  distinctly  marked  by  a small  sharp  gray  line,  which, 
beginning  insensibly  at  the  anterior  part  of  the  body,  becomes  more 
distinct  as  it  extends  backwards,  and  is  ultimately  found  to  bend 
gently  toward  the  median  plane.  There  it  unites  with  a similar 
elevated  line  of  the  opposite  optic  eminence : and  to  the  point  of 
union  is  attached  a small  conical  body  with  a minute  point,  of  a 
gray  colour,  and  of  a shape  like  that  of  the  pine-apple.  This  is 
the  object  improperly  termed  pineal  gland ; {glandula pinealis,  eon- 
arium\  Die  Zirbel-driise ; Beil);  and  the  minute  linear  emi- 
nences or  tracts,  which  form  the  inner  edge  of  the  upper  optic  sur- 
face, have  been  named  peduncles  of  the  pineal  gland.  The  inner 
surface  of  the  optic  couch  or  chamber  presents  nothing  important, 
save  the  small  portion  of  soft  cerebral  matter,  which  unites  it  to  the 
similar  surface  of  the  opposite  body.  Its  posterior  edge,  however, 
is  terminated  by  the  cerebral  limb  of  that  side ; and  the  lower  edge 
meets  that  of  the  opposite  one,  and  is  connected  to  it  by  a portion 
of  brain,  which,  examined  in  this  manner,  has  received  no  name, 
but  forms  the  lower  part  of  the  middle  ventricle.  The  portion  of 
brain  which  corresponds  to  it  on  the  outside  (base  of  the  brain)  has 
been  named  the  bridge  of  Turin.  {Pons  Taririi.')  This  is  the  tri- 
angular space  between  the  limbs  of  the  brain  which  has  been  called 
by  Vicq-D’Azyr  the  pit  of  the  oculo-muscular  nerves.  It  may  be 
named  the  triangular  intercrural  hollow. 

The  posterior  surface  of  the  optic  eminence  is  the  most  impor- 
tant, but  the  least  understood.  It  is  so  intimately  connected  with 
the  inferior,  that  in  description  they  cannot  be  easily  distinguished. 
Santorini,  I believe,  was  the  first  who  observed  that  the  posterior 


250 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


part  of  the  optic  couch  was  terminated  by  a projection  or  process, 
wliich  he  named  the  jointed  or  geniculate  body,  and  which,  he  had 
likewise  the  merit  of  observing,  gives  rise  to  the  optic  nerve.* * * § 
More  recently  Malacarne  remarked  that  this  region  is  rendered 
unequal  by  a tubercle,  from  which  the  nerves  seem  partly  to  rise.| 
About  the  same  time  it  was  noticed  by  Vicq-D’Azyr,  that  on  the 
side,  a little  behind  and  below,  there  are  three  superficial  tuber- 
cles of  a rounded  figure,  and  disposed  in  a triangle  ; and  that  one 
of  them  must  have  been  the  body  mentioned  by  Gunz  and  Bon- 
homme,  and  of  which  Hallei^ avowed  his  ignorance. J He  after- 
wards mentions  a slight  prominence  near  the  upper  of  the  four 
eminences,  of  a white  colour,  but  gray  exteriorly,  communicating 
with  the  optic  tract  ;§  while  the  external-lateral  region  of  the  optic 
couch  presents  several  similar  eminences,  but  less  considerable. 
The  notice  given  by  Bicbat  is  still  more  brief  and  less  satisfactory 
“ Tout  a fait  en  arriere  cette  parti  inferieure  ofFre  une  ou  deux 
saillies,  et  se  continue  avec  les  tubercules  quadrijumeaux.” 

The  inaccurate  manner  in  which  these  authors  seem  to  have  exa- 
mined this  part  of  the  organ,  the  vague  and  imprecise  terras  in 
which  they  speak  of  it,  as  if  its  existence  were  apocryphal, — show 
the  necessity  of  more  correct  researches.  Soemmering  and  Gor- 
don describe  in  this  situation  two  eminences,  termed  the  outer  and 
inner  geniculate  bodies.  The  description  of  the  former  author  is 
brief  and  precise,  but  not  quite  so  satisfactory  as  could  be  wished. 
That  of  the  latter  is  more  minute  ; but  in  some  respects  it  is  either 
not  clear,  or  it  does  not  apply  generally. 

* “ Quod  tamen  per  repetitas  diligenterquo  institutas  disquisitiones  ab  eadem  potius 
membi-ana  eos  non  proficisci,  seepius  vidisse  vissus  sum  ; vemm  turn  ab  eorum  Thala- 
morum  interiori  parte,  turn  a quodam  vdut  gcnicvilato  corpora  circa  corundem  Thala- 
morum  posteriora  locato  adjimctoque,  cujus  eorticalis  sen  cinerea  interior  substantia 
est,  medullaris  et  Candida  exterior  facies  luculentius  prodire,  sum  assecutus  : Ad  ho- 
rum  tamen  exortus  locum  a latere  prominentiarum  quod  natiformes  nuncupantur, 
conspicuus  medullaris  tractus  transversim  sic  Thalamis  conjungitur,  ut  vel  in  eorum 
substantia  disjiciatur,  vel  inflexus  caeterisqiie  fibrillis  involutus  ad  Nervorum  ojrticorum 
exortum  accedat,  conjicere  quidem,  decernere  autem  minime  valui.”  Observat.  Ana- 
tomic. Joan.  Dorn.  Santorini,  cap.  iii.  § 14.  See  also  a more  minute  description  in  his 
posthumous  Tabulae  Anatomicce,  Tabula  iii.  fig.  1.  p.  32.  Parm£e,  1775. 

f “ La  stessa  faccia  superiore — e coperta  d’una  lamina  midollare  tenuissima  ed  ha 
disuguale  la  posteriore  estremita  per  un  hernacolo  irregola/i'c,  da  cui  sembra  che  in 
parte  usscono  i nervi  ottici.”  Articolo,  vii.  63. 

Elementa  Physiologies,  Tom.  IV.  lib.  x.  sect.  1.  § 24. 

§ Recherches  sur  la  Structure  du  Cerveau,  &c.  ix.  Memoires  de  I’Academie 
Roy  ale  des  Sciences,  Annee  1731. 


BRAIN. 


251 


The  confusion  and  uncertainty  which  prevails  on  this  part  of  ce- 
rebral anatomy,  induced  me  to  adopt  a method  which  I find  to  be 
more  certain  in  unfolding  the  objects  in  question,  and  which  may 
be  safely  recommended  to  the  practical  anatomist.  Let  the  brain 
be  examined  from  below,  and  let  the  examination  commence  with 
the  optic  tracts.  That  the  acceptation  of  this  term  may  he  definite, 
I observe  that  the  optic  nerves  should  be  in  accuracy  counted  from 
the  commissure  only.  The  cerebral  extremity  or  origin,  as  it  is 
named,  of  a nerve,  should  be  reckoned  from  that  point  only  at 
which  it  is  quite  free  in  its  whole  circumference  from  the  organ. 
This  happens  to  the  optic  nerves  at  the  anterior  part  of  the  com- 
missure only  ; for  behind  this  body  the  longitudinal  hands  called 
tracts  adhere  by  one  side  (the  outer)  to  the  cerebral  substance.  A 
narrow  angular  sinuosity,  admitting  the  point  of  a small  probe,  is 
found  at  the  inner  or  mesial  edge  of  the  tracts ; hut  beyond  this 
they  adhere  indissolubly.  As  they  pursue  their  course  backward 
and  outward,  they  reach  the  limbs  of  the  brain,  the  inferior  sur- 
face of  which  they  cross,  still  adhering  by  their  outer  edge,  brtf 
more  extensively.  Here  likewise  they  ar£  sensibly  broader  than 
at  their  anterior  end. 

When  they  have  passed  completely  the  limbs  of  the  brain,  at 
which  they  are  about  the  breadth  of  three  lines,  they  begin  to  pre- 
sent a linear  furrow  or  depression,  which  extends  in  their  long  di- 
rection about  one-half  or  three-fourths  of  an  inch,  and  thus  divides 
the  tract  into  an  outer  and  an  inner  limb.  This  depression,  how- 
ever, does  not  divide  the  tract  equally,  but  leaves  the  outer  broader 
than  the  inner  limb.  It  is  insensibly  terminated  at  the  upper  sur- 
face of  the  optic  eminence  or  chamber ; and  its  last  part,  (about 
three  or  four  lines,)  contemplated  with  care,  will  he  found  to  sepa- 
rate two  spheroidal  eminences  which  are  respective  terminations  of 
the  outer  and  inner  limbs  of  the  tract.  The  outer  of  these  emi- 
nences is  the  largest  and  most  prominent,  and  is  the  body  mention- 
ed by  authors  as  the  posterior  tubercle  of  the  optic  chamber.  It  is 
the  body  which  Santorini  named  the  geniculate,  (corpus  quiddam 
geniculatum ;) — an  epithet  for  which  it  is  not  easy  to  account,  un- 
less we  suppose  that  his  fancy  had  likened  it  to  the  appearance  of 
a bent  joint,  especially  that  of  the  knee,  to  which,  if  viewed  lateral- 
ly in  connection  with  the  tract,  it  bears  some  remote  resemblance. 
It  is  broader,  larger,  and  more  convex  than  the  inner  eminence, 
and  is  evidently  the  chief  origin  of  the  optic  tract.  The  eminence 


252 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


on  the  inside  of  the  linear  furrow  is  much  smaller,  and  often  less 
distinctly  marked  than  the  outer.  In  ordinary  circumstances  it 
may  be  described  as  an  eminence  of  cerebral  matter  contained  be- 
tween two  circular  segments,  in  such  manner  that  its  longitudinal 
extent,  which  is  nearly  vertical,  is  greater  than  its  transverse.  It 
is  obviously  connected  with  the  smaller  limb  of  the  optic  tract. 
Whether  this  body  actually  takes  its  origin  from  the  four  eminen- 
ces {corpora  quadrigeminal  depends  on  evidence  of  a different  de- 
scription. 

The  inner  or  mesial  side  of  the  geniculate  bodies  is  contiguous 
to  the  four  eminences,  and  is  separated  from  them  by  a linear  fur- 
row. These  eminences  occupy  the  upper  surface  of  the  protube- 
rance, and  partly  that  of  the  limbs  of  tbe  brain,  and  the  linear  fur- 
row marks  the  point  at  which  the  limbs  issue  from  the  substance  of 
the  optic  couches.  The  lower  surface,  indeed,  of  these  bodies  pre- 
sents tbe  long  thick  cylinder  of  the  limbs  ; and  while  they  occupy 
this  conspicuous  situation,  and  a considerable  proportion  of  the 
lower  surface,  it  is  impossible  to  assign  them  more  cerebral  space 
above,  than  that  occupied  by  the  upper  two  of  the  four  eminences 
(nates^)  and  the  adjoining  part  of  the  optic  couch. 

This  view  of  the  objects  occurring  in  this  region  of  the  figurate 
surface,  will  show  the  formation  and  arrangement  of  the  inner 
border  of  the  communication.  It  will  be  seen  that  it  consists  of 
successive  portions  of  that  figurate  surface,  proceeding  from  the 
mesial  line,  on  each  side  to  the  lower  and  outer  margin  of  the  cere- 
bral limbs.  It  will  be  seen,  that,  if  we  begin  at  the  longitudinal 
furrow  of  the  four  eminences,  we  find  first  the  upper  eminence  of 
one  side ; then  the  contiguous  part  of  the  optic  couch  ; then  the 
greater  geniculate  eminence ; after  this,  as  the  cylindroid  process 
pursues  its  winding  and  revolute  course,  the  outer  part  of  the  cere- 
bral limb ; and,  lastly,  the  outer  and  lower  angle  of  that  limb. 

Not  only,  however,  does  the  convoluted  surface  of  the  brain 
communicate  with  the  figurate  one,  but  the  laminated  surface  of 
the  cerebellum  communicates  with  the  analogous  surface  of  that 
organ,  and  thus  with  the  great  figurate  surface.  This  communi- 
cation takes  place  on  the  middle  plane,  below  the  transverse  or 
middle  plates  which  form  the  pyramid,  uvula,  and  nodule,  and  be- 
tween these  bodies  and  tbe  restiform  processes.  This  is  the  fourth 
ventricle  of  anatomical  writers ; and  as  it  has  never  been  denied 
that  it  communicates  with  the  outer  surface  of  the  cerebellum,  it  is 


BRAIN. 


253 


noticed  here  merely  as  an  integrant  part  of  those  views  which  I 
apply  to  the  organ  at  large. 

The  central  or  figurate  surface  exposed  in  the  manner  now  ex- 
plained is  smooth,  polished,  and  possesses  a degree  of  firmness  and 
closeness  of  texture  which  prevents  it  from  being  readily  broken 
or  abraded.  These  qualities  are  ascribed  by  Reil  to  a thin  mem- 
branous pellicle,  which  he  terms  Epithelion^  and  with  which  he 
conceives  the  proper  matter  of  the  brain  is  covered.*  Trusting  to 
ordinary  inspection,  aided  by  a good  glass,  I do  not  think  there  is 
any  sensible  proof  of  the  existence  of  this  covering.  It  is  moi’e 
natural  to  regard  it  as  cerebral  matter  modified  for  its  situation. 
In  point  of  fact,  the  deep  cerebral  matter  may  be  rendered  equally 
firm  with  this  by  immersion  in  alcohol  or  dilute  acids.  But  no- 
thing can  give  the  smooth,  polished,  close-grained  surface  which 
belongs  to  every  spot  of  this  part  of  the  brain.  After  this  expla- 
nation, I shall  not  scruple  to  use  the  term  Epithelion,  not  in  the 
sense  given  by  Reil,  but  merely  as  a name  to  the  firm  smooth  sub- 
stance which  forms  the  figurate  surface  of  the  brain. 

In  certain  situations  this  surface  is  unusually  firm,  for  instance 
in  the  narrow  winding  hollow  between  the  striated  bodies  and  the 
optic  eminences.  ( Centrum  semicirculare  geminum^  Vieussens ; 
tania  semicircularis,  Haller.)  Of  the  central  surface,  not  only 
docs  every  division  mutually  communicate,  but  the  whole  central 
surface  of  the  convoluted  brain  communicates  with  the  central  sur- 
face of  the  laminated  part  of  the  organ.  Thus  the  lateral  divisions, 
called  ventricles,  communicate  freely  and  directly  with  each  other 
below  the  vault  or  twain-band ; (^fornix.  Die  Zwillingshinde ;)  the 
surface  of  which  lies  free  over  the  top  of  the  thalami.  These  again 
communicate  with  the  intermediate  space  called  the  third  ventricle, 
from  which  it  is  well  known  there  is  a passage  to  the  space  between 
the  medulla  oblongata  and  the  cerebellum.  The  communication 
with  the  posterior  and  infeidor  divisions,  {cornua),  is  well  known. 

The  whole  of  this  surface  is  covered  by  a vascular  membrane, 
which  is  a continuation  of  that  {pia  mater)  of  the  convoluted  sur- 
face. One  part  of  this  which  lies  over  the  objects  in  the  lateral 
ventricles  has  been  long  known  under  the  name  of  choroid  plexus  ; 
and  an  intermediate  portion  by  which  those  of  the  two  sides  are 
united,  has  been  distinguished  by  the  term  velum  interpositum. 
Not  only  are  each  of  these  parts  of  the  same  membrane,  and  con- 

• Archiv.  fiir  die  Physiologie,  9ter  Band,  3.  Untersuchungen,  &c.  p.  143. 


254 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


nected  with  the  pia  mater ; but  individual  portions  of  vascular 
membrane  or  choroid  plexus,  all  continuous,  are  found  in  every 
division  of  the  figurate  surface  of  the  brain.  This  membrane  sus- 
tains the  vessels  going  to  and  issuing  from  the  cerebral  substance. 

Between  the  two  surfaces  now  described  is  placed  the  proper 
matter  of  the  brain,  which  in  different  regions  of  the  organ  is  ar- 
ranged differently.  The  intimate  arrangement  peculiar  to  indivi- 
dual parts,  and  the  manner  in  which  the  arrangement  of  each  is 
mutually  connected,  are  now  to  become  the  object  of  examination. 

The  convoluted  surface  first  claims  attention.  The  colour  of 
this  is  well  known  to  be  of  an  ash-gray,  passing  in  certain  parts 
to  pale  brown.  In  whatever  part  the  substance  of  the  convolutions 
be  examined,  they  never  present  any  appearance  of  linear  or  fibrous 
arrangement.  I have  often  examined  the  convoluted  substance  of 
the  human  brain  after  induration  in  alcohol  and  dilute  nitric  acid ; 
and  I never  could  recognize  the  distinct  fibrous  disposition  ob- 
served in  other  parts  of  the  organ.  A portion  of  brain,  hardened 
in  the  manner  now  mentioned,  breaks  with  a small  conchoidal  frac- 
ture, and  an  uneven  granular  subordinate  surface.  The  surface 
thus  exposed  presents,  however,  a very  determinate  aspect,  which 
it  is  easy  to  recognize  after  repeated  trials.  It  is  ash-gray  and 
without  lustre.  It  is  rough,  and  consists,  when  minutely  examined, 
of  roundish  grains  aggregated  togetlier.  The  direction  of  the  frac- 
ture is  more  at  right  angles  to  the  convoluted  surface  than  obliquely 
or  parallel  to  it.  In  some  instances  even  it  is  possible  to  recognize 
depressed  marks  perpendicular  to  the  surface,  sending  off  angu- 
larly like  branches  smaller  depressed  marks,  meeting  similar  rami- 
fications from  other  perpendicular  depressions. 

I have  often  attempted  to  determine,  by  breaking  portions  of 
brain  in  every  direction,  whether  this  appearance  is  uniform  ; but 
I cannot  say  that  I have  obtained  satisfactory  proof  of  the  point. 
I am  not  unaware  that  Reil  represents  the  intimate  structure  of  the 
convolutions  to  be  distinctly  fibrous.  So  far  as  I understand  his 
description,  I admit  the  fact  of  the  conchoidal  fracture  which  I 
have  often  verified  ; but  I am  not  prepared  to  allow  that  this  arises, 
as  he  imagines,  from  the  fibrous  matter  being  arranged  in  plates 
or^^leaves,  which  are  folded  and  rolled  together.*  Upon  the  whole, 
the  convoluted  substance  I regard  as  chiefly  granular,  but  so  ar- 
ranged as  to  be  more  frangible  in  the  direction  perpendicular  to 
’ Archiv.  fiir  die  Physiologie  neunter  Band,  p.  145. 


BRAIN. 


255 


its  surface  than  otherwise.  It  is  said  to  he  more  abundantly  sup- 
plied with  vessels  than  the  white  matter ; (Ruysch,  Albinus,  Pro- 
chaska,  Soemmering,  and  Ehrenberg;)  and  indeed  a great  number  of 
large  vessels  enters  it  all  over,  and  especially  at  certain  parts,  e.  g. 
the  perforated  space  of  the  Sylvian  fissure.  It  is  not,  however,  abso- 
lutely and  at  all  points  more  vascular  than  the  white  matter.  The 
transition  from  the  gray  convoluted  matter  to  the  white  inclosed, 
is  in  all  parts  of  the  hemispheres  sudden  and  distinct.  It  is  more 
distinct,  however,  after  induration  by  immersion  in  alcohol  or  di- 
lute acid  than  in  the  recent  brain. 

The  only  part  of  the  convoluted  surface  which  presents  a distinct 
fibrous  arrangement  is  that  part  of  the  Sylvian  fissure  which  has 
been  named  by  Reil  the  unciform  bundle;  (der  haakenfdrmigeMark- 
biindel).  This,  however,  can  scarcely  be  said  to  belong  to  the 
convoluted  surface.  It  is  situate  on  the  outside  of  the  perforated 
spot,  and  corresponds  with  a short  smooth  convolution,  which  passes 
between  the  middle  and  the  anterior  lobes.  The  unciform  bundle, 
in  short,  unites  these  lobes,  and  is  intimately  connected*  with  the 
internal  arrangement  of  the  nucleus  and  its  capsule,  parts  immedi- 
ately to  be  noticed. 

The  white  cerebral  matter  is  arranged  in  various  parts  of  the 
organ,  in  the  form  of  inconceivably  minute  parallel  lines,  lying  in 
juxtaposition.  It  is  unnecessary  to  enumerate  all  the  parts  in  which 
this  arrangement  may  be  observed;  and  greater  advantage  will 
result  from  a short  view  of  the  mutual  relation  and  connection  of 
the  fibrous  parts  of  the  organ,  so  far  as  they  are  well  ascertained. 

In  tracing  this  part  of  the  intimate  structure  of  the  brain,  several 
anatomists  have  imbibed  the  notion  that  one  part  of  the  brain  gives 
rise  to  or  generates  another.  From  this  assumption  even  Reil  is 
not  wholly  exempt.  Without  entering  on  the  subject  of  organo- 
genesy,  or  the  question  of,  which  part  of  the  brain  in  the  foetal  ex- 
istence is  first,  and  which  subsequently  formed, — which  will  be  con- 
sidered in  its  own  place — I begin  wdth  stating,  that  in  the  adult 
every  part  of  the  organ  is  supposed  to  be  coeval ; that  the  idea  of 
one  part  generating  or  reinforcing  another  is  an  effort  of  fancy 
which  must  not  be  admitted  in  strict  science ; that  when  a bundle 
of  fibres,  or  a fibrous  arrangement,  is  seen  proceeding  from  one 
part  to  another,  it  is  imagination  only  which  suggests  that  the  for- 
mer produces  the  latter,  or  conversely ; and  that  from  this  nothing 
Archiv.  fiir  die  Physiologie,  9ter  Band,  pp.  184,  197,  and  201. 


256 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


more  can  be  inferred  than  that  the  parts  so  arranged  are  mutually 
and  generally  connected. 

The  inner  fibrous  part  of  the  brain  proper  is  divided  by  Reil  into 
the  system  of  the  brain-limbs  {crura Das  Hirnschenkel-system  ;) 
the  system  of  the  beam  or  mesolobe,  (Das-Balken  system ;)  and  the 
striated  ganglion  (das  gestreifte  Hirnganglion ;),  and  to  one  or 
other  of  these  he  refers  the  arrangement  of  all  the  other  parts  of 
which  the  organ  is  composed.  I do  not  adopt  all  his  views,  nor  is 
it  requisite  to  follow  his  distinctions  minutely.  But  I shall  attempt 
to  trace  briefly  what  I conceive  admits  of  demonstrable  proof. 

The  beam  or  mesolobe,  {corpus  callosum^  Der  Balken}  consists 
of  white  cerebral  matter  disposed  in  transverse  fibres,  which  meet 
on  the  mesial  plane,  and  thus  give  rise  to  the  longitudinal  lines 
seen  on  its  upper  surface  {Raphe  externa  et  iaterria,  Reil).  They 
appear  to  change  direction,  and  bend  down  at  right  angles,  parallel 
with  those  of  the  opposite  half.  At  the  distance  of  from  four  to 
five  lines  on  each  side,  these  transverse  fibres  undergo  a similar 
interruption  or  change  of  direction,  so  as  to  form  the  covered  bands 
(die  bedeckten  Bander),  which  appear  also  in  the  form  of  long,  firm, 
fibrous  lines,  extending  longitudinally  along  the  upper  surface  of 
the  beam.  Between  these  bands  and  the  inner  margin  of  the  olfa- 
cient  groove  a connection  may  be  traced  over  the  knee  (das  Knie), 
or  anterior  end  of  the  heam. 

Beyond  the  covered  bands  the  transverse  fibres  pass  directly  into 
the  white  matter  of  the  hemispheres,  where  they  are  connected  in 
diflPerent  modes  with  different  parts.  The  general  direction  is  that 
of  expansion,  like  the  rods  of  a fan,  or  radiation,  like  the  rays  of  a 
luminous  body.  The  fibres  which  compose  the  knee  or  anterior 
end,  sinking  into  the  hemisphere  near  the  anterior  cornu,  meet 
those  forming  the  first  and  anterior  staff"  of  the  brain- limb,  which 
lie  in  the  anterior  knotty  end  of  the  striated  body,  and  wind  round 
the  adjoining  edge  of  the  staff-wreath  ; (der  Stabkranz).  In  the 
intermediate  substance,  which  is  knotty  before,  and  spreads  into  a 
brush-shaped  expansion  behind,  the  middle  rods  of  the  staff-wreath 
unite  with  their  anterior  extremities,  and  with  the  fibres  of  the 
beam.  This  forms  the  first  or  anterior  junction  of  the  heam  with 
the  limbs. 

The  middle  fibres,  passing  immediately  into  the  hemisphere, 
meet  more  abruptly  with  those  of  the  limbs  Suddenly  contract- 
ing, as  it  were,  they  coalesce  with  those  of  the  taenia,  and  are  co- 


BRAIN. 


257 


vered  by  the  gray  matter  of  the  brush-like  termination  above-men- 
tioned, and  epithelion,  which  is  here  very  thick.  The  radiating 
fibres  of  both  systems  are  here  shortest.  The  deep  layers  form  in 
some  parts  immediate  mutual  communications,  especially  in  the 
posterior  cornu ; and  at  this  point  alone  the  inner  layer  of  the  beam 
descends  directly  on  the  fibres  of  the  limb.  In  expansion,  these 
radiating  fibres  receive  between  them  white  matter  from  the  hemi- 
spherical circumference ; and  in  this  manner  form  connections,  as 
remarked  by  Reil,  with  the  peripheral  or  convoluted  part  of  the 
hemispheres,  and  especially  with  those  which  form  the  Sylvian  fis-- 
sure.*  This  may  be  considered  the  second  connection  of  the  beam 
with  the  brain  limbs. 

The  hinder  part  of  the  beam  is  something  firmer  than  the  fore 
part  reckoned  towards  the  centre  ; a circumstance  which  depends 
on  the  closeness  with  which  its  fibres  are  here  compacted  in  mass. 
After  forming  the  elevated  ridge  which  constitutes  the  hinder  cross- 
bar of  the  vault,  they  plunge  into  the  hemispheres  in  the  form  of 
thick  bundles,  which,  running  horizontally  backwards  over  the 
posterior  cornu,  are  expanded  in  the  posterior  parts  of  the  hemi- 
spheres. The  inner  layer  of  these  fibres,  which  falling  on  the  outer 
wall  of  the  cornu  over  the  radiation  of  the  limbs,  covers  it  and  part 
of  the  outer  wall,  is  named  by  Reil  the  tapestry,  or  hanging.  (Die 
Tapete. ) This  may  be  viewed  as  a third  point  of  junction  between 
the  beam  and  the  brain  limbs. 

I am  now  to  trace  the  direction  of  the  component  fibres  of  the 
latter  parts.  These  are  connected  below,  above,  and  behind,  with 
so  many  important  parts,  that  it  is  requisite  to  comprehend  several 
parts  under  the  general  denomination  of  System  of  the  limbs.  After 
the  example  of  Reil,  we  begin  from  the  head  of  the  spinal  chord ; 
(medulla  oblongata.) 

This  part  consists  in  the  human  adult  of  six  eminences,  three  on 
each  side  of  the  mesial  plane  ; the  pyramidal  or  pyriform  eminences 
before  and  below,  the  restiform  bodies  behind  and  above,  and  the 
olivary  eminences  on  each  side.  Of  these  the  olivary  eminences  are 
to  be  viewed  as  the  most  important,  since  by  each  containing  a ci- 
liary or  moriform  nucleus,  (corpus  ciliare,  c.  dentatum,  c.  moriforme, 
c.  rhomboideum,)  they  make  an  approach  in  structure  to  the  cha- 
racter of  the  cerebellum. 

The  pyriform  or  pyramidal  bodies  are  important  in  another  light 

* Archiv.  f Ur  die  Physiologie,  Neunter  Band,  p.  179. 

K 


258 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Varoli,  who  has  the  merit  of  first  examining  with  attention  what 
is  termed  tlie  base  of  the  brain,  traced  in  these  bodies  longitudinal 
fibres  passing  upwards  through  the  body,  named  after  him  Pons 
VaroUi,  the  annular  protuberance^  {jnoiuberantia  annularis  ; Wil- 
lis ; nodus  cerebri;  Rau;)  towards  the  limbs  and  substance  of  the 
brain.  By  Vieussens  and  Morgagni  the  fact  of  this  arrangement 
was  afterwards  verified ; and  it  has  been  confirmed  by  the  obser- 
vations of  Reil  on  the  adult  brain,  and  by  those  of  Tiedemann  in  the 
foetal  organ. 

The  pyramidal  bodies,  situate  on  the  anterior -part  of  the  medulla 
oblongata,  and  mutually  separated  by  the  median  furrow,  consist 
entirely  of  bands  or  rods  of  whitish  fibres,  (Die  Mark  Stabchen,) 
extending  longitudinally  through  them.  Becoming  thicker,  but 
not  less  compact  at  the  upper  end,  where  they  are  connected  with 
the  part  named  bridge,  {pons  Varolii ; die  Brucke ;)  or  annular 
protuberance ; {nodus  cerebri  ;)  these  longitudinal  fibres  undergo  a 
new  arrangement.  First,  They  are  covered  with  a firm  layer  of 
transverse  fibres,  which  proceed,  as  it  were,  from  the  middle  line 
on  each  side  circularly  round.  These  fibres  are  white,  firm  trans- 
versely, and  abundantly  distinct.  ^ When  peeled  off  to  the  depth 
of  about  1^  line  or  two,  the  longitudinal  fibres  of  the  pyramids  be- 
gin to  appear  ; but  no  longer  collected  in  mass  as  below.  Nume- 
rous transverse  or  circular- transverse  fibres  are  interposed  between 
them,  so  as  to  separate  them  into  layers.  Hence  results  the  com- 
plex structure  of  the  bridge,  which  externally  appears  to  consist  of 
circular-transverse  matter,  but  internally  presents  many  longitudi- 
nal bands.  It  is  worthy  of  notice,  that  in  transverse  and  longitu- 
dinal sections  the  part  which  appears  gray  on  the  transverse  section, 
is  white  on  the  longitudinal,  and  conversely.  The  closeness  with 
which  the  circular  fibres  are  compacted  render  the  bridge  decidedly 
the  firmest  part  of  the  whole  brain. 

Proceeding  from  the  lower  to  the  upper  surface  of  the  bridge, 
this  combination  of  long  and  cross  bands  is  less  distinct.  Part,  if 
not  the  whole  of  the  transverse  fibres,  sink  into  the  peduncles  or 
cru7-a  of  the  cerebellum  ; and  they  evidently  predominate  here  over 
the  longitudinal. 

The  posterior-upper  part  of  the  medulla  oblongata  consists  of  two 
longitudinal  bodies  separated  on  the  median  line  by  a deep  furrow. 
These,  which  are  the  restiform  or  rope-like  processes,  chordal  pro~ 
cesses  of  Ridley,  {corpora  restiforrhia)  {processus  restiformes,  Mor- 

3 


BRAIiV. 


259 


gagni,)  are  described  in  most  works  as  the  pyramidal  eminences. 
(Haller,  Malacarne,  Red.)  As  there  is  no  doubt  that  this  part  of 
the  spinal  chord  presents  six  eminences,  three  on  each  side,  as  above 
stated,  with  the  view  of  avoiding  the  confusion  with  which  anato- 
mists speak  on  these  bodies,  I adhere  to  the  plan  originally  adopted 
by  Willis,  Ridley,  Ruysch,  and  Morgagni,  of  distinguishing  the 
anterior  eminences  as  ■pyramidal^  and  the  posterior  as  the  restiform 
■processes* 

Stretching  in  the  form  of  thick  strong  bands  between  the  pe- 
duncles of  the  cerebellum  above,  and  the  spinal  chord  below,  the 
restiform  processes  are  mutually  parted  by  a deep  furrow,  (calamus 
scriptorius,)  in  the  bottom  of  which,  when  slightly  separated,  white 
chords  proceeding  from  the  process  of  one  side  are  observed  to  be 
plaited  or  crossed  with  those  of  the  other.  This  arrangement  was 
first  observed  by  Dominico  Mistichelli,t  a physician  at  Rome,  in 
1709,  and  shortly  after  by  Pourfour  dePetitJ  at  Namur.  Though 
subsequently  verified  by  the  observation  of  Santorini,§  Win- 

* “ The  third  descends  from  this  part  (the  cerebellum)  backwards  upon  the  upper 
.side  of  the  medulla  oblongata,  like  two  longish  thick  chords  on  each  side,  making  the 
medulla  look  somewhat  thicker  and  broader  in  that  place,  and  not  unfitl}'  styled  the 
chordal  process."  The  Anatomy  of  the  Brain,  &c.  By  H.  Ridley,  Coll.  IMed.  Bond. 
Soc.  London,  1695,  chap.  xiv.  j).  136.  Of  this  the  term  processus  restiformis  is  a 
literal  translation,  given  by  his  Latin  translator,  and  in  the  collection  of  Mangetus. 
It  is  remarkable,  that,  though  thus  earR  noticed  by  Ridley,  and  afterwards  distin- 
giushed  as  posterior  pyramidal  eminences  by  Ruysch,  the  restiform  processes  have 
been  completely  neglected,  and  are  scarcely  known  even  bj'  name.  It  is  not  uncom- 
mon both  in  books  and  in  demonstration  to  see  them  pointed  out  as  the  corpora  py- 
ramidalia.  By  those  who  wish  to  avoid  the  confusion  resulting  from  this  oversight, 
they  are  termed  posterior  pyramidal  bodies  ; and  in  support  of  this,  the  authority  of 
Ruysch,  Prochaska,  and  Soemmering'*  may  be  adduced. 

T Trattato  dell’  Apoplessia.  Roma,  1709.  Lib.  i.  Cap.  vi.  ix. 

t Lettre  d’un  Medecin  des  Hospices  du  Roi.  Namur,  1710. 

§ “ Nos  autem  sic  earn  luculenter  conspeximus,  sic  eHdenter,  ubi  apta  incidere  ca- 
davera  demonstravimus,  ut  nulla  amplius  nobis  de  hac  re  supersit  dubitandi  ratio.  Id 
autem  triplici  potissimum  in  loco  animadvertere  potuimus  ; in  utraque  scilicet  priore 
posterioreque  annularis  protuberantiae  crepidine,  atque  maxime  in  imo  medullaris  cau- 
dicis,  qua  in  spinalem  abit.  In  priore  itaque  annularis  protuberantire  parte,  qua  supe- 
rius  reflexa  pro  comprehendendis  oblongatre  medullas  cruribus  in  anguli  formam  in- 
terius  producta  tenuatur,  sic  ex  concurrentibus  fibris,  strictiorique  agmine  coeuntibus, 
altera  alteram  scandit,  ut  praeter  mirum  implexum,  decussatio  luculentissime  appareat. 
Id  ipsum  ferme  in  postica  ipsius  crepidine  occurrit.  Eo  iterum  in  loco,  qui  quarto  ven- 
triculo  subjicitur,  (the  space  between  the  restiform  processes,)  praeter  varios  fibrarum 


* Frederic!  Ruyschii  Responsio  ad  M.  E.  Ettmuller  de  Corticali  Cerebri  Substantia,  &c.  p.  25.  Am- 
stel.  172li  Georgii  Prochaska  De  Structura  Nervorum  Tractatus,  &c.  Sectio  3.  tabula  i.  fig.  1.  S.  T. 
Soemmering  De  Basi  Encepha'i,  &c.  Tab.  U.  sect.  3.  § 18.  Apud  Ludwig,  Tom.  II. 


260 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


slow,*  Lieutaud,  and  Soemmering,-}-  it  had  escaped  the  notice  of  Hal- 
ler, Vicq-D’Azyr,  Monro,  and  others,  and  was,  therefore,  doubted 
till  revived  by  M.  Gall.  Independent  of  the  testimony  of  the  above 
authors,  it  is  easy  to  demonstrate  by  slight  separation  of  the  resti- 
form  bodies  the  fact,  that  whitish  chords  are  seen  lying  obliquely 
across  the  linear  depression,  and  that  those  connected  with  the  right 
process  cross  to  the  left,  while  conversely  those  of  the  left  cross  to 
the  right. 

It  is  to  the  inner  or  mesial  fibres  of  the  restiform  processes  only 
that  this  cross  plaiting  is  confined.  Neither  the  pyramidal,  nor  the 
olivary,  nor  even  the  whole  of  the  restiform  bodies  partake  of  it. 
It  is  sufficient,  however,  to  establish  a communication  between  the 
right  and  left  halves  of  this  part  of  the  spinal  chord.  It  was  seen 
by  Tiedemann  in  the  fourth  and  fifth  weeks  of  uterine  life. 

The  interior  fibres  of  these  bodies  are  longitudinal,  and  proceed 
partly  to  the  cerebellum,  partly  to  the  protuberance.  The  deep- 
seated  layer  is  partly  interwoven  with  the  transverse  circular  fibres 
of  this  body,  in  the  same  manner  in  which  those  of  the  pyramidal 
eminences  are,  partly  bends  up  to  the  peduncles  of  the  cerebellum, 
with  the  bands  of  which  they  are  then  combined.  The  superficial 
layer  is  connected  chiefly  with  the  substance  of  the  corpora  quadri- 
gemina,  (Die  Vierhugel,)  which  constitute  the  upper  surface  of  the 
protuberance. 

The  structure  of  the  olivary  body  is  more  complex.  Though  its 
surface  consists  of  longitudinal  fibres,  which,  like  those  of  the  other 
eminences,  are  lost  in  the  protuberance,  these  form  a sort  of  super- 
ficial covering  to  a capsule  of  gray  matter  arranged  in  a serrated 
form,  inclosing  a nucleus  of  white.  This  arrangement  constitutes 
a ciliary  or  moriform  body,  (corpus  ciliare,  c.  dentatum^  c.  rliom- 
boideum^)  precisely  similar  to  that  in  the  white  trunks  of  the  cere- 

ordines  et  colores,  in  adversum  latus  productas,  et  decussatas  fibras  cximmode  specta- 
vimus.  Si  ea  tamen  evidenter  uspiam  conspicitur,  profecto  quam  evidentissime  duas 
vix  lineas  infi'a  pyramidalia,  atque  adeo  olivaria  corpora  conspici  potest.  Qua  enim 
in  longitiidinem  producta  linea,  seu  rimula  pyramidalia  corpora  (the  restiform  pro- 
cesses) discernuntur,  si  leniter  diducantur,  probe  prius  eo  potissimum  loco  artissime 
hserente  tenui  meninge  nudata,  non  tenues  decussari  fibrillas  sed  validos  earundem  fas- 
cicvlos  in  adversa  contendere,  quam  apertissime  demonstravimus.”  Observ.  Anatom. 
J.  D.  Santorini.  Lug.  Bat.  1739.  Cap.  3,  § 12.  p.  61.  Also  Tab.  II.  apud  Girardi, 
p.  28,  29. 

* Exposition  Anatomique,  &c.  Par  J.  B.  Winslow.  Paris,  1732.  Traite  de  la 
Teste,  110,  p.  626. 

t S.  T.  Soemmering  de  Basi  Encephali,  lib.  ii.  sect.  3.  § 18. 


BRAIN. 


261 


helium,  to  which,  therefore,  the  olivary  eminence  approaches  in  or- 
ganization. 

All  these  parts  may  be  viewed  as  external  markings  on  the  bulb 
of  the  spinal  marrow,  {medulla  oblongata.)  It  is  to  be  observed, 
that  in  the  foetus,  the  infant,  and  in  young  subjects  in  general, 
they  are  more  distinct,  than  in  the  brains  of  adults  and  especially 
of  the  aged.  In  the  brains  of  infants  and  the  young,  all  the  mark- 
ings both  separating  furrows  and  elevations  are  most  distinct ; 
and  the  restiform  bodies  or  posterior  pyramidal  bodies  present  each 
a longitudinal  furrow,  parting  them  in  two  portions,  one  lying 
close  on  the  median  line  and  furrow,  the  other  lying  between  their 
median  and  most  posterior  portions  and  the  olivary  bodies.  To 
these  sometimes  the  name  of  posterior  pyramidal  bodies  is  applied, 
and  the  name  appears  sometimes  to  be  applied  to  the  restiform 
bodies,  while  that  of  restiform  bodies  is  given  to  these  anterior 
portions  of  the  posterior  masses,  still  regarded  as  posterior  pyra- 
mids. 

As  life  advances  this  longitudinal  furrow  becomes  less  distinct, 
and  at  length  is  so  small  as  to  be  imperceptible  in  many  adult  and 
aged  persons.  This  is  the  reason  of  the  discordance  in  the  state- 
ments of  different  anatomists. 

In  the  infant  brain,  therefore,  and  in  that  of  the  young,  the 
medulla  oblongata  is  marked  or  distinguished  externally  into  eight 
bodies,  or  four  on  each  side  of  the  mesial  plane.  At  this  period  of 
life  also,  each  of  the  four  lateral  bodies  is  more  strongly  figured, 
and  appears  in  more  distinct  relief  than  in  the  brain  examined  at  a 
subsequent  period. 

In  the  brain  of  the  young,  also,  the  internal  structure  is  if  pos- 
sible more  strongly  marked  than  in  that  of  the  aged.  It  is  then 
seen,  that  the  longitudinal  fibres  of  the  bulb  are  interlaced  or  in- 
terwoven with  numerous  transverse  fibres ; that  the  corpora  resti- 
forma  are  closely  connected  with  the  peduncles  of  the  cerebellum ; 
that  the  anterior  pyramids  are  connected  or  continuous  with  the  crura 
of  the  brain  ; and  that  the  olivary  bodies,  by  presenting  a corpus 
dentatum.,  form  a repetition  of  the  cerebellum  in  the  spinal  marrow. 

The  longitudinal  fibres  of  these  several  parts  passing  through 
the  protuberance  are  observed  beyond  this  body  to  be  in  direct 
continuation  with  those  of  the  cerebral  limbs.  ( Crura,  Die  Hirn- 
schenkel.)  These  are  cylindrical  masses,  stretching  obliquely  be- 
tween the  protuberance  behind  and  the  optic  chambers  or  eminences 


262 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


before.  The  longitudinal  bands  of  which  they  consist  give  their 
lower  surface  a fluted  appearance,  at  least  to  the  inner  margin  of 
the  optic  tracts,  by  which  they  are  obliquely  crossed.  Connected 
before  with  the  posterior-inferior  region  of  the  tlialami,  they  may 
be  traced  into  the  substance  of  these  parts,  where  they  undergo  an 
arrangement  new  and  peculiar. 

Though  the  name  couch  or  thalamus  be  still  applied  to  these 
bodies,  it  conveys  an  erroneous  idea  of  their  anatomical  relations. 
With  the  striated  bodies,  they  form  the  central  portion  and  most 
perfectly  organized  nucleus  of  the  organ. 

Each  optic  thalamus  may  be  said  to  be  united  behind  with  its 
fellow  by  means  of  the  quadrigeminous  eminences.  These  con- 
sist superficially  of  epithelion  or  capsular  cerebral  matter,  below 
of  a semilunar  stratum  of  fibres  derived  from  the  cerebral  limbs, 
while  a similar  production  forms  the  deep  layer  of  the  corpus  geni- 
culaturn  internum. 

In  each  optic  thalamus  may  be  distinguished,  according  to  Reil, 
four  layers,  each  consisting  of  gray  and  white  matter.  The  up- 
permost is  merely  the  epithelion  or  condensed  matter  which  forms 
the  covering.  The  second  is  connected  with  the  inner  corpus  ge- 
niculatum.^  from  which  fibres  appear  to  spread  or  expand  in  the 
manner  of  rays,  over  the  outer  edge  of  the  limb,  and  embracing 
the  part  to  he  mentioned  as  the  nucleus  of  the  brain.  The  third 
layer  consists  of  a set  of  fibres  which,  issuing  from  the  upper  layer 
of  the  brain-limb  at  their  entrance  into  the  thalamus,  are  firmly 
tied  as  it  were  into  a loop  or  knot,  (die  Schleife,)  and  are  then 
expanded  like  a brush  into  the  substance  of  the  thalamus.  The 
lower  is  formed  chiefly  by  the  cerebral  limb.  It  is  partly  in  the 
former,  partly  in  the  latter,  that  the  dark-coloured  matter  consti- 
tuting the  locus  niger  is  placed. 

The  thalamus  is  so  intimately  connected  with  the  limbs,  that  they 
must  be  viewed  as  essential  parts  of  the  same  organized  whole. 
The  component  rods  or  fibrous  bands  (seine  Markstabchen)  of  the 
latter,  partly  combining  with  the  former,  but  chiefly  receiving  them, 
spread  out  near  the  outer  edge  of  the  thalamus  circularly,  and  con- 
stitute the  radiated  expansion  called  by  Reil  the  StafFwreath. 
(Der  Stab-Kranz.)  These  rods,  at  first  obliquely  horizontal,  gra- 
dually, as  they  expand,  assume  a more  vertical  direction.  Inwards, 
or  towards  the  mesial  plane  from  the  first  band  or  rod  ascends  the 
anterior  pillar  of  the  Twainband  { fornix)  to  the  knobs  of  the  beam. 


BRAIN. 


263 


Then  follow  the  first  band  or  spoke  of  the  wreath,'  and  the  rest  in 
succession.  The  anterior  rods  are  long,  slender,  numerous,  and 
thickly  crowded  on  each  other.  The  middle  or  lateral  are  short, 
thick,  roll-like,  and  form  a sort  of  crest  or  comb.  The  posterior 
are  long  and  of  fibrous  structure.  As  they  expand  they  form 
nearly  a complete  circle,  which  radiates  through  all  the  lobes. 
The  radii  of  this  circle  are  connected  in  the  anterior  lobes  with  the 
knee  of  the  beam,  cross  thejTos-sa  Si/lvii  near  the  anterior  and  pos- 
terior cornua  to  the  outer  edge  of  the  thalamus,  and  terminate  in 
the  lateral  coi'nu  in  the  apex  of  the  middle  lobe,  at  the  beginning 
of  the  Sylvian  furrow.  In  this  course  the  anterior  rays  of  the 
StafFwreath  are  longer  than  the  middle  and  lateral  rays,  the  inter- 
ruption of  which  forms  the  comb  or  crest.  (Der  Kamm.)  The  pos- 
terior, which  go  to  the  border  of  the  outer  wall  of  the  capsule,  are 
the  longest ; and  shorter  ones  are  again  seen  below  in  the  region 
of  the  lateral  cornu. 

The  last  part,  the  organization  of  which  can  be  here  made  the 
subject  of  short  consideration,  is  the  striated  body.  When  ob- 
served, this  part  presents  a singular  arrangement  of  white  and  gray 
matter  in  the  form  of  alternate  streaks.  This  arrangement,  though 
constant,  it  is  unnecessary  to  describe  minutely,  unless  so  far  as  it 
is  connected  with  the  appearances  already  mentioned.  The  parts 
which  chiefly  claim  attention  on  this  head  are  the  cerebral  nucleus^ 
its  capsule,  and  the  loalls  of  the  capsule. 

The  striated  part  of  the  brain  may  be  regarded  as  a nucleus, 
(Der  Kern)  or  organized  central  mass,^  which  is  contained  within 
a capsule  consisting  of  three  walls  or  enclosing  plates  of  white  mat- 
ter ; a lower,  an  outer,  and  an  inner  wall. 

The  lower  wall  of  the  capsule,  which  is  accidental,  consists  chiefly 
of  the  tractus  innominatus,  (Die  ungenannte  Marksubstanz,)  the 
perforated  spot,  and  that  part  of  the  convoluted  space  from  which 
the  olfacient  nerve  issues. 

The  outer  wall  is  the  most  remarkable.  It  rests  on  the  unciform 
band  (Der  haakenformige  Markbiindel)  at  the  entrance  of  the  Syl- 
vian fossa,  which  connects  the  convolutions  of  the  anterior  lobes  by 
the  perforated  spot  with  the  middle  lobe.  F rom  this  unciform  band 
as  a centre,  the  fibres  of  the  whole  outer  wall  radiate ; and  as  the 

ReiJ  considers  it  a ganglion,  (Das  Gestreifte  grosse  Himganglium.)  But  this  idea 
is  hypothetical  ; and  while  I use  the  term  nucleus,  I vdsh  to  convey  no  idea  but  that 
of  one  part  contained  within  another. 


264 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


deep  ones  are  beneath  the  level  of  the  cerebral  limb,  Reil  regards 
them  as  connected  neither  with  this  nor  with  the  beam  or  raesolobe. 
He  represents,  nevertheless,  the  radiation  of  the  outer  wall  as  too 
much  detached  from  the  unciform  band.  Frequent  examination 
of  this  part  leads  me  to  represent  the  outer  wall  and  the  unciform 
band  as  parts  of  the  same  system  of  fibres.  The  unciform  band  is 
situate  not  on  the  same  vertical  plane  with  the  rest  of  the  outer 
wall,  which  not  only  radiates  in  every  direction  forward,  upward, 
and  backward,  but  swells  out  laterally,  or  towards  the  convoluted 
region  of  the  hemispheres.  The  result  of  this  arrangement  is,  that 
the  section  which  shows  the  unciform  band  most  distinctly  shows 
only  the  peripheral  or  marginal  fibres  of  the  outer  wall.  A sec- 
tion more  external  or  lateral,  however,  shows  the  radiating  fibres 
of  the  part  between  the  centre,  (the  unciform  process,)  and  the  cir- 
cumference ; and  in  order  to  see  them  distinctly  all  at  once,  and 
to  have  a correct  conception  of  their  assembled  disposition,  it  is  re- 
quisite to  pare  off  from  its  outer  surface  the  exterior  white  matter, 
or  to  excavate  externally,  so  as  to  form  a spherical  segment. 

The  outer  wall  of  the  capsule  is,  in  short,  a spherical  shell,  con- 
sisting of  fibres  radiating  from  a point  above  the  fossa  Sylvii.  So 
far  as  1 have  been  able  to  observe,  it  has  no  connection  with  the 
limbs  of  the  brain. 

The  inner  wall  of  the  capsule  is  composed,  on  the  contrary,  of 
the  stem  of  the  limb,  and  the  fore-part  of  the  staffwreath,  which 
sends  fibres  under  the  round  part  of  the  inner  portion  of  the  nu- 
cleus. Joining  the  outer  wall  above  by  means  of  an  arched  mar- 
gin, and  at  acute  angles,  it  gives  the  capsule  the  shape  of  an  in- 
verted boat. 

In  this  capsule  is  lodged  the  outer  part  of  the  large  striated  nu- 
cleus of  the  brain;  the  inner,  usually  named  corpus  striatum,  being 
covered  only  by  epithelion  within  the  ventricle.  Both  are  parts  of 
one  organ  which  should  not  be  separated. 

Of  the  cerebellum,  the  internal  arrangement  is  nearly  the  fol- 
lowing. 

The  restiforra  processes  I have  already  mentioned  as  connected 
partly  with  the  protuberance,  partly  with  the  four  eminences,  {cor- 
pora quadrigemina),  situate  on  its  upper  surface.  The  circular 
transverse  fibres  of  the  protuberance,  which  enclose  the  longitudinal 
ones  produced  in  a lateral-posterior  direction,  plunge  into  the  ce- 
rebellic  hemispheres  in  the  form  of  thick,  strong,  white  chords, 

4 


BEAIN. 


265 


named  stalks  or  peduncles  of  the  cerebellum.  At  the  point  at  which 
they  take  this  direction,  they  further  receive  a considerable  accession 
from  the  restiforra  processes,  the  fibres  of  which  are  here  seen  to 
make  a slight  bend  upwards,  in  order  to  follow  the  direction  of  the 
peduncles.  Thus  is  composed  a thick  strong  trunk  of  white  matter, 
which  on  each  side  forms  a sort  of  central  pillar,  (Die  Marksaule, 
Der  Pfeiler,)  to  each  cerebellic  hemisphere.  The  interior  arrange- 
ment of  this  pillar  or  trunk  is  distinctly  fibrous  longitudinally,  at 
its  origin,  or  parting  from  the  protuberance,  and  for  a considerable 
distance  from  this  point  through  the  hemisphere.  Unless  I am 
misled  by  optical  deception,  the  part  derived  from  the  restiforra 
processes  is  also  fibrous,  and  changes  direction,  to  accord  with  that 
of  the  peduncular  bands. 

In  the  centre  of  the  white  fibrous  pillar  thus  formed  is  contained 
a body  consisting  of  a capsule  of  fibrous  matter  enclosing  a nucleus 
of  white.  The  serrated  or  indented  form  in  which  both  the  nucleus 
and  its  capsule  are  arranged  gives  it  the  name  of  ciliary  or  mori- 
form  body  ; {corpus  ciliare  v.  dentatum^  c.  moriforme  or  rhomboi- 
deum.)  The  capsule  is  incomplete  at  one  end,  that  turned  towards 
the  base  or  root  of  the  trunk.  Each  trunk  or  stem  (Stamm)  divides 
into  a certain  number  of  branches,  (Aeste) ; each  branch  into  a 
number  of  twigs  (Zweige ;)  and  to  each  twig  is  attached  a number 
of  leaves.  (AbZ/a  ; Blattchen.) 

Of  these  plates  or  leaves  the  structure  is  uniformly  the  same, 

white  matter  internally,  covered  with  a thicker  layer  of  gray. 
Whether  the  white  is  really  fibrous  or  not,  as  Reil  describes,  is  not 
easy  to  say,  in  consequence  of  its  extreme  tenuity  and  small  quan- 
tity. It  is  certainly  fibrous  in  the  stems  and  branches,  in  which 
the  linear  appearance  can  be  seen  almost  by  the  eye,  and  always 
by  a glass.  I cannot  say  that  it  is  so  evident  in  the  twigs,  in  which 
it  is  in  very  small  quantity ; and  in  the  leaves  the  intimate  dispo- 
sition is  still  more  difficult  to  recognize.  In  the  gray  matter  it  is 
impossible  to  trace  any  thing  like  fibrous  structure. 

The  ramification  (die  verzweigung,  die  zerastelung,)  in  the  cere- 
bellic hemispheres  is  connected  with  the  circular-transverse  fibres 
of  the  protuberance  and  the  restiforra  processes  exclusively.  Some 
would  say  that  from  this,  this  ramification  is  derived, — the  precise 
meaning  of  which  I have  already  endeavoured  to  determine.  In 
the  middle  of  this  organ,  however,  or  on  its  mesial  plane,  is  found 
a ramification  which  appears  to  be  connected  with  a different  source. 


266 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Tills  is  the  structure  of  the  upper  and  lower  worm.  Between  the 
lower  of  the  quadrigeminous  eminences  and  the  cerebellum  is  a 
thick  semicylindrical  hand  on  each  side,  known  under  the  name  of 
pillars  of  the  valve^  and  processus  a cerehello  ad  testes.  These  a 
little  below  the  lower  margin  of  the  valve  seem  to  sink  directly  into 
the  cerebellic  substance,  mutually  join,  and  form  a whitish  stem, 
which  is  ramified  in  the  middle  of  the  cerebellum.  About  four 
lines  or  half  an  inch  from  their  first  entrance  into  the  organ,  a 
branch  set  off  almost  straight  upwards  is  the  vertical  branch,  (Der 
Stehende  Ast,)  which,  after  giving  off  its  first  twig  (der  erste  zweig) 
to  the  central  lobe,  divides  into  other  seven,  which  are  distributed 
to  the  anterior  or  mesial  lobules  of  the  quadrilateral  lobes,  as  they 
meet  on  the  mesial  plane.  The  white  stem  of  this  vertical  branch 
is  thick  and  large. 

A more  slender  stem,  the  continuation  of  the  original  white 
band,  proceeding  horizontally  backwards  towards  the  purse-shaped 
notch,  is  the  horizontal  stem  (Der  Liegende  Ast,)  which  constitutes 
by  ramification  a number  of  important  parts  on  the  mesial  plane  of 
the  cerebellum.  After  giving  three  or  four  twigs  generally  small, 
and  also  vertical,  to  the  last  leaves  of  the  quadrilateral  lobes,  the 
branches  are  parted  in  the  following  order  : — 1 st,  A twig  under 
the  cross  commissures  of  the  posterior-upper  lobes,  forming  the 
short  exposed  ci'oss-hands  (die  Kurzen  und  sichfbaren  Querbander,) 
and  the  long  covered  cross-bands ; (die  verdeckten  und  langen 
Querbander;) — 2d,  A branch  dividing  into  three  strong  twigs, 
forming  the  leaves  of  the  pyramid ; — ‘del,  A long  branch  dividing 
into  three  twigs,  forming  the  leaves  of  the  uvula  (der  Zapfen  ;) — 
Ath,  The  last  generally  a single  twig,  constituting  the  laminar  tu- 
bercle or  nodule  (das  Knotchen.) 

The  spinal  chord  is  the  last  part  of  the  central  class  of  organs 
coming  under  the  head  of  brain.  It  may  be  viewed  as  two  longi- 
tudinal bands  united  by  the  middle.  Both  are  fibrous  internally 
throughout  their  entire  length ; and  in  the  lumbar  region  of  the 
canal  these  fibres  are  separated  and  expanded  into  a true  brush-like 
arrangement,  named  cauda  equina.  Some  anatomists  have  ima- 
gined they  could  recognize  cross  fibres  in  the  chord  ; but,  with  the 
exception  of  what  has  been  stated  regarding  the  connection  of  the 
restiforra  processes,  nothing  of  this  nature  can  be  regarded  as  esta- 
blished. 

Some  anatomists  have  also  thought  it  possible  to  demonstrate 


BRAIN. 


267 


the  existence  of  a longitudinal  cavity  or  canal  in  the  spinal  chord. 
In  the  adult  this  never  exists  in  the  normal  state.  The  canal  of 
the  chord  is  part  of  the  foetal  structure  only  ; and  in  this  respect  it 
is  to  he  viewed  as  one  of  many  peculiarities  of  formation  belonging 
to  the  lower  animals,  through  which  the  human  foetus  passes  in 
the  early  stage  of  development.  A longitudinal  canal  is  found  in  the 
spinal  chord,  during  the  whole  course  of  existence,  in  reptiles,  fishes, 
and  birds.  In  mammiferous  animals  in  general  it  is  always  found 
in  the  foetus,  and  continues  in  several  for  some  time  after  birth. 
(Sewel,  F.  Meckel,  and  Tiedemann.)  As  the  animal  grows,  how- 
ever, it  ceases  to  be  found ; and  the  only  trace  of  its  previous  ex- 
istence is  a longitudinal  depression  on  the  anterior  part  of  the 
chord.  In  the  young  of  the  human  subject  it  has  been  found  after 
birth  by  Charles  Stephen,  by  Columbo,  Piccolhomini,  Bauhin, 
Malphighi,  I^yser,  Golles,  Morgagni,  Haller,  and  Portal.  No 
doubt  can  be  entertained,  however,  that  in  such  cases  it  was  part 
of  the  foetal  structure  continued  to  an  unusual  period  by  the  slow 
progress  of  growth,  or  in  consequence  of  some  interruption  to  th« 
usual  process  of  development.  The  chord,  in  short,  is  formed  in 
two  portions;  and  when  these  are  incomplete,  the  longitudinal 
cavity  exists  between  them.  As  by  progressive  enlargement  they 
mutually  approximate  on  the  mesial  plane,  this  canal  necessarily 
diminishes  until  it  entirely  disappears. 

I am  now  to  consider  shortly  the  minute  anatomical  structure 
of  cerebral  matter  in  the  several  parts  of  the  organ.  The  three  di- 
visions of  brain,  small  brain,  and  vertebral  prolongation,  and  their 
constituent  parts,  do  not  present  every  where  the  same  aspect  or 
obvious  qualities,  but  appear  to  consist  of  substances  which  are  dis- 
tinguished chiefly  by  their  colour. 

The  outer  convoluted  part  of  the  first  division  {cerebrum)  con- 
sists of  peculiar  substance  of  a gray  or  ashen  colour.  Its  convo- 
luted surface,  which  is  covered  by  the  adherent  surface  of  the  soft 
or  vascular  membrane,  {meninx  tenuis^  pia  muter),  is  smooth  and 
uniformly  gray,  without  spots  or  streaks.  At  various  situations  it 
presents  minute  holes  or  orifices,  which  correspond  to  arterial  or 
venous  branches.  It  is  not  easy  to  apply  accurate  terms  to  denote 
the  kind  of  colour ; but,  according  to  Gordon,  this  surface  is  of  the 
wood-brown  or  lead-gray  tinge;*  and  the  substance  so  coloured 


Same’s  Nomenclature  of  Colours. 


268 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


extends  only  one-eighth  or  one-tenth  of  one  inch  in  depth,  and  is 
then  succeeded  hy  a tinge  of  orange-white  substance.  Of  the  cor- 
rectness of  this  ohservation,  I am  not  assured.  If  sections  of  the 
convoluted  part  he  made,  no  difference  can  be  observed  in  the  re- 
cent brain ; and  the  cut  surface  appears  to  consist  of  homogeneous 
and  uniform  gray  matter,  from  the  outer  or  free  margin  to  that 
which  adheres  distinctly  to  the  white  substance. 

The  consistence  of  the  convoluted  cerebral  substance  is  consi- 
derable ; but  it  is  less  than  that  of  the  white  matter. 

If  we  trust  to  the  observations  of  Father  Della  Torre,  the  gray 
and  the  white  substance  of  the  brain,  cerebellum  and  spinal  chord, 
consist  of  an  accumulation  of  transparent  globules,  floating  in  a 
transparent  crystalline^  but  somewhat  viscid  fluid.*  These  globules, 
he  imagined,  are  largest  in  the  brain,  smaller  in  the  cerebellum, 
and  still  smaller  in  the  spinal  chord. 

According  to  the  observations  of  Prochaska,  however  different 
in  colour  the  gray  cerebral  substance  be  from  the  white,  no  differ- 
wce  in  minute  structure  can  be  recognized  by  the  most  powerful 
lens.  Each  appears  to  consist  of  an  infinite  multitude  of  globules, 
connected  by  a peculiar,  elastic  band ; and  he  observes  that  this 
cerebral  globule  does  not  float  in  a fluid,  as  Della  Torre  imagined, 
but  is  connected  to  the  contiguous  ones  by  a thin  and  transparent 
cellular  web,  (tela  cellulosa  suhtilissima  et  pellucidissima^)  which  is 
a series  of  membranous  partitions  derived  from  the  soft  membrane 
and  minute  vessels.  This  last  conclusion  is  not  quite  certain,  and 
would  require  to  be  made  the  subject  of  further  researches. f 

On  the  structure  of  these  globules  nothing  is  known  with  cer- 
tainty. They  are  not  exactly  spherical,  but  are  said  to  be  irregu- 
larly round.  The  observation  of  Della  Torre,  that  they  are  largest 
in  the  convoluted  brain,  (cerebrum,)  smaXXev  in  the  laminated,  (cere- 
bellum,) and  most  minute  in  the  vertebral  portion,  is  fanciful,  and 
perhaps  unfounded.  Prochaska,  however,  admits  that  the  globules 
are  not  all  of  the  same  size,  but  that  it  is  impossible  to  ascribe  their 
variable  magnitude  to  a regular  principle,  unless  the  proximity  or 
remoteness  of  the  lens.J 

The  accuracy  of  these  observations  is  confirmed  in  general  by 

* Nuove  Observazione  Microscopicbe.  Napoli,  1776.  Osserv.  16, 17,  18,  19,  &o. 
t Georgii  Prochaska  De  Structura  Nervorum,  &c.  VienuEe,  1779.  Sectio  2,  ca- 
put iv. 
t Ibid. 


BRAIN. 


269 


the  testimony  of  Soemmering,  whose  inferences,  derived  from  the 
observations  of  Lewenhoek,  Della  Torre,  Malacarne,  Metzger,  and 
Prochaska  himself,  are  found  in  the  conclusion  of  his  description 
of  this  organ.* 

From  thirty-one  experimental  observations  on  the  cerebral  mat- 
ter of  the  human  subject,  in  various  mammiferous  animals,  fowls, 
and  fishes,  Joseph  and  Charles  Wenzel  of  Tubingen  have  drawn 
the  conclusion ; — that  the  gray  and  white  (cortical  and  medullary) 
matter  of  the  human  brain,  the  substance  of  the  colliculi,  (optic 
chambers  and  striated  bodies,)  that  of  the  conarium,  spinal  chord, 
and  nerves ; in  short,  the  mass  of  brain  in  mammiferous  animals, 
birds,  and  fishes,  consists  of  the  same  small  roundish  bodies,  mu- 
tually cohering,  of  which  the  substance  of  muscle,  liver,  spleen, 
and  kidney  is  composed ; that  as  these  minute  bodies  derive  their 
shape  from  the  cells  of  the  cellular  tissue,  the  substance  of  brain, 
spinal  chord,  and  nervous  matter,  appears  to  consist  of  the  same 
roundish  minute  bodies ; but  that  the  relative  size  of  these  cells 
cannot  be  determined. 

These  conclusions  throw  little  light  on  the  point  at  issue, — the 
minute  structure  of  the  cerebral  matter  in  general ; and  it  must 
be  said  that  the  microscopical  observations  and  chemical  experi- 
ments of  these  anatomists  do  not  communicate  information  propor- 
tioned either  to  their  number,  or  to  the  elaborate  assiduity  with 
which  they  appear  to  have  been  conducted.  Subsequently  the  atomic 
constitution  of  different  parts  of  the  brain  and  cerebellum  was  in- 
vestigated by  Sir  Everard  Home,  aided  by  the  powerful  microscopes 
of  ]\I.  Bauer. 

According  to  this  observer,  white  cerebral  matter  consists  of  in- 
numerable globules,  aggregated  or  connected  in  rows,  so  as  to  con- 
stitute fibres,  by  means  of  a transparent,  colourless,  jelly-like  mat- 
ter, somewhat  viscid,  elastic,  and  readily  soluble  in  water.  The 
globules  are  whitish,  semitransparent,  and  vary  from  24^0  to 
of  an  inch  in  diameter,  the  average  being 

Upon  different  proportions  of  these  two  constituent  elements,  and 
partly  upon  differences  in  size  of  the  component  globules,  the  chief 
peculiarities  of  structure  in  the  several  sorts  of  cerebral  substance 
depend.  Thus  the  gray  matter  of  the  convoluted  surface  of  the 
brain,  and  the  laminated  simface  of  the  cerebellum,  consists  chiefly 
of  globules  from  gg^gg  to  jgigg  of  uo  iuch  in  diameter,  the  smaller 

* Samuelis  Thomae  Soemmering  De  Corporis  Humani  Fabrica,  Tom.  III.  Tra- 
jecti  ad  Moenum,  1800. 


270 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


globules  being  most  numerous,  of  a large  proportion  of  the  gela- 
tinous, elastic,  viscid  substance,  and  a yellowish  fluid  resembling 
the  serum  of  the  blood,  probably  albuminous.  In  the  white  mat- 
ter, on  the  contrary,  the  large  globules  (4550  of  inch)  predomi- 
nate ; the  connecting  jelly  is  more  tenacious,  but  less  abundant  in 
proportion  to  the  globules ; and  the  latter  are  more  distinctly  ar- 
ranged in  rows,  so  as  to  constitute  fibres. 

The  mesolobe  contains  the  greatest  quantity  of  the  small  glo- 
bules (34^55  of  an  inch ;)  and  the  viscid  jelly  is  said  to  be  at  least 
equal  to  the  globules  in  quantity.  In  the  limbs  of  the  brain  and 
peduncles  of  tlie  cerebellum,  the  jelly  is  said  to  be  in  greater  pro- 
portion than  the  globules.  The  annular  protuberance  is  chiefly 
composed  of  globules  of  the  average  size  (53505)  with  abundant  vis- 
cid matter.  In  the  restiform  processes,  the  pyramidal  bodies,  and 
the  olivary  eminences,  the  fibrous  structure  consists  chiefly  of  the 
large  globules,  with  abundant  viscid  jelly,  which  is  rapidly  soluble 
in  water.* 

When  the  brain  by  immersion  in  alcohol  is  hardened,  the  elastic 
jelly  is  coagulated  and  rendered  opaque,  and  the  appearance  of 
globules  is  lost.*j* 

These  observations  partly  verify  those  of  Della  Torre,  partly  ex- 
plain those  of  Prochaska.  They  show,  that,  so  far  as  the  micro- 
scope can  be  trusted,  the  globules  of  which  cerebral  matter  consists 
vary  in  size  and  proportion  in  different  parts ; and  that  the  white 
cerebral  matter  generally  consists  of  larger  globules,  or  at  least 
contains  a larger  proportion  of  these  globules  than  the  gray. 

The  observations  by  Ehrenberg  in  1833J  on  this  subject  next 
deserve  attention.  * 

This  observer,  by  using  the  compound  microscope,  found  the  fol- 
lowing forms  of  organic  structure  in  the  brain  and  nerves  : — 

1.  A substance  consisting  partly  of  very  minute  fine  grains,  with 
some  coarser  grained  matter,  disseminated,  as  is  said  in  the  lan- 
guage of  mineralogy,  through  the  fine-grained  matter.  The  latter 
is  entirely  confined  to  the  gray  matter  of  the  convoluted  surface  of 
the  brain,  and  the  laminated  surface  of  the  cerebellum. 

■*  The  Croonian  Lecture.  Microscopical  Observations  on  the  Brain,  &c.  By  Sir 
Everard  Home,  Bart.  V.  P.  R.  S.  Philosoiihical  Transactions,  JR21,  Part  i.  v.  p.  25. 

i-  The  Croonian  Lecture.  On  the  Internal  Structure  of  the  Human  Brain,  &c.  By 
Sir  Everard  Home,  Bart.,  V.  P.  Philosoirhical  Transactions,  1824,  p.  3. 

+ Ehrenberg  employed  a microscope  manufactured  by  Chevalier  of  Paris,  and  aug- 
mented in  Power  by  Pistor  and  Schiek  of  Berlin  ; and  the  powers  varied  from  260'  to 
360  diameters. 


BRAIN. 


271 


2.  A set  of  tubes  presenting  at  definite  intervals  globular  or 
spheroidal  expansions,  so  as  to  resemble  a string  of  beads,  which  do 
not  touch  each  other,  but  have  a short  communicating  space  inter- 
posed between  each  bead.  To  these  tubes  he  gives  the  name  of 
varicose^  from  their  resemblance  to  the  varices  of  a vein,  and  jointed 
or  articulated  tubes,  because  of  the  slight  resemblance  to  a set  of 
joints.  These  tubes,  which  present  to  the  microscope  the  appear- 
ance of  parallel  fibres,  he  shows  by  various  proofs  to  have  an  in- 
ternal cavity  or  canal,  and  to  contain  a peculiar  matter,  to  which 
he  assigns  the  name  and  qualities  of  nervous  fluid.  These  are  con- 
fined chiefly  to  the  white  matter  of  the  brain.  They  may  be  termed 
moniliform  tubes. 

3.  A set  of  tubes  straight  and  uniform,  without  the  alternate 
spheroidal  enlargements,  also  hollow,  and  to  which  he  applies  the 
name  of  simple  cylindrical  tubes.  These  are  found  chiefly  in  the 
nervous  chords  and  trunks.  They  are  generally  lai’ger  and  coarser 
than  the  articulated  tubes.  But  at  certain  points  the  latter  pass 
into  the  former  by  gradually  losing  their  bead-like  enlargements. 
These  tubes  Ehrenberg  represents  to  be  distinguished  from  the  ce- 
rebral jointed  tubes,  by  containing  in  their  interior  a viscid,  white, 
but  less  transparent  matter,  to  which  he  applies  the  name  of  me- 
dullary. 

The  substance  of  the  circumference  or  the  convoluted  part  of 
the  brain  consists  of  a thick,  very  delicate,  vascular  network,  con- 
veying often  numerous  blood-globules,  and  traversed  by  serpen- 
tine tendinous  fibres.  Besides  the  thick  delicate  vascular  net  of  the 
first  substance,  Ehrenberg  saw  in  the  same,  near  its  utmost  edge 
and  its  remotest  circumference,  a very  fine-grained  soft  substance, 
in  which  here  and  there  are  imbedded  larger  grains  or  nuclei.  These 
large  grains  are  free,  and  consist  of  granules  or  nucleoli  which  are 
connected  in  rows  by  means  of  slender  threads  to  the  fine  small 
grains  of  the  substance  singly.  In  the  neighbourhood  of  the  me- 
dullary substance,  the  fibrous  character  of  the  cortical  matter  al- 
ways appears  more  distinctly  ; and  in  the  same  substance  the  blood- 
vessels are  larger  and  less  numerous. 

The  white  or  medullary  matter  of  the  brain  shows  more  distinct- 
ly the  arrangement  of  fibres,  which  proceed  in  the  form  of  direct 
and  enlarging  continuations  of  the  delicate  cortical  fibres,  from 
certain  eminences,  that  is,  the  linear  or  band-like  origins  of  the 
convoluted  surface,  in  a radiated  manner,  towards  the  hrain.  These 


272 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


are  not  simple  cylindrical  fibres ; but  resemble  bollow  strings  of 
pearls,  the  component  parts  of  winch  are  not  in  contact,  but  are 
connected  by  a canal  for  a small  space ; or  they  resemble  tubes  or 
cylindrical  canals  dilated  at  intervals  into  minute  bladders.  These 
bladders  or  ampullulcB  of  the  tubes  were  known  to  Leeuwenhoek, 
who  regarded  them  as  globules  of  fat,  which  constituted  the  greatest 
part  of  the  brain.  The  connecting  canals  also  he  has  obscurely 
indicated.  These  tubes,  uniformly  straight,  are  generally  parallel 
in  direction,  sometimes,  however,  crossing  each  other.  Four  times 
Ehrenberg  recognised  ramification  in  such  individual  canals ; but 
anastomoses  he  never  observed.  These  tubes  vary  in  diameter 
from  to  of  one  line. 

In  the  neighbourhood  of  the  base  of  the  brain  and  in  the  matter 
surrounding  the  ventricles,  there  are  always  seen  between  these 
bundles  of  nodulated  or  jointed  tubes,  individual  tubes  much  thicker 
than  the  rest.  In  these  thick  tubes  it  is  often  possible  to  recognise 
in  their  walls  an  external  and  internal  boundary ; or  they  present, 
besides  their  two  external  boundary  lines,  other  two  inner  lines, 
which  enable  the  observer  to  distinguish  the  width  of  the  area  of 
the  internal  cavity  of  the  tubes.  These  nodulated  linear  parts  of 
the  brain  are  varicose  articulated  tubes  or  canals. 

The  large  cerebral  tubules  of  the  cerebral  matter  converge  to- 
wards and  pass  into  those  parts  of  the  base  of  the  brain,  where  the 
peripheral  nerves  arise.  Some  of  the  large  jointed-tube-matter 
appears  to  terminate  in  or  be  connected  with  the  cerebral  cavities, 
in  the  walls  of  which  it  is  well  developed.  Many  jointed  or  vari- 
cose tubes  pass  into  tbe  spinal  marrow,  and  tbence  immediately 
proceed  to  the  spinal  nerves. 

In  the  spinal  marrow  the  arrangement  now  described  is  in  some 
respects  reversed.  In  the  brain  the  most  vascular  and  delicate 
structure  is  placed  at  the  exterior ; while  the  least  vascular,  but 
perhaps  more  organised,  viz.  the  varicose  tubular  structure,  is  placed 
at  the  interior.  In  the  spinal  chord  the  most  vascular  and  delicate 
part  lies  in  the  centre ; while  it  is  covered  externally  by  the  coarse 
medullary  matter. 

Both  substances  are  quite  like  those  in  the  brain.  From  the  ex- 
ternal medullary  matter,  consisting  of  large  varicose  or  monilifonn 
tubes,  the  spinal  nerves  immediately  proceed ; and  these  varicose 
or  jointed  tubes,  as  they  emerge  from  the  investing  dura  mater, 
assume  suddenly  the  form  of  nerve-tubes,  becoming  thicker  and 


BRAIN. 


273 


passing  into  the  pure  cylindrical  form.  These  transitions  are  easily 
recognised  in  the  posterior  part  of  the  spinal  marrow. 

The  optic,  the  auditory,  and  the  olfactory  nerves  are  immediate 
continuations  of,  or  productions  from,  the  varicose  medullary  tubes 
of  the  brain.  All  the  other  nerves,  excepting  the  sympathetic  in 
the  middle  of  its  course,  differ  from  the  cerebral  matter. 

All  these  other  nerves  also  consist  only  of  cylindrical  parallel- 
lying  tubes,  about  t igth  part  of  a line  in  diameter,  normally  never 
anastomosing.  These  are  the  elementary  nerve-tubes,  which,  united 
in  fasciculi  or  bundles,  again  form  larger  bundles,  which  constitute 
the  nerve-chords. 

These  are  the  chief  facts  ascertained  by  Ehrenberg  regarding 
the  minute  structure  of  the  brain  and  spinal  chord.  These  have 
been  mostly  confirmed  by  Berres  and  Muller.  By  others  again 
the  accuracy  of  these  results  has  been  called  in  question.  Thus 
the  observations  of  Treviranus,  Valentin,  and  Weber  tend  to  show 
that  all  the  primitive  cerebral  fibres  or  tubes  are  cylindrical,  and 
that  the  varicose  or  raoniliform  appearance  is  an  efiect  of  compres- 
sion; or  the  violence  employed  in  subjecting  them  to  microscopic 
observation.  Muller,  nevertheless,  admits  that  the  primitive  cerebral 
tubes  have  great  proneness  to  become  varicose  or  beaded. 

The  only  points  which,  amidst  the  discordance  of  the  results  of 
different  microscopical  observers,  from  Leewenhoek  and  Fontana 
to  Ehrenberg,  Berres,  Treviranus,  and  Muller,  can  be  regarded 
as  established,  are  the  following  ; that  the  convoluted  portion  of  the 
brain  consists  of  very  minute  granules  or  nucleoli  arranged  in  rows 
so  as  to  form  fibres,  which  radiate  from  the  periphery  to  the  inner 
boundary  of  the  convoluted  portion  ; that  near  the  inner  boundary, 
and  as  they  approach  the  white  cerebral  matter,  this  fibrous  ar- 
rangement becomes  more  distinct;  and  that  the  white  cerebral 
matter  forming  the  walls  of  the  ventricles  and  the  base  of  the  brain 
is  composed  of  tubular  cylinders,  mostly  of  large  size,  and  having 
a cylindrical  cavity ; but  whether  these  are  varicose  or  not  seems 
undetermined.* 

* C.  G.  Ehrenberg  in  PoggendorfF’s  Annalen  der  Physik  und  Chemie,  Jahrg.  1833. 
Band  XXVIIL  § 449-65,  und  1834.  Band  XXXIV.  § 76,  80.  Also  Beobachtung 
einer  bisher  unbekannten  auffallenden  structur  des  Seelenorgan  bei  Menschen  und 
Thieren.  Von  C.  G.  Ehrenberg.  Gelesen  in  der  Akademie  der  Wissenschaften  am 
24  October  1833.  Gedruckt  im,  Feb.  1836.  Abhandlungen  ; seite  665.  Translated, 
with  Additions  and  Notes.  By  Baud  Craigie,  M.  D.  Edinburgh  Medical  and  Surgical 
Journal,  Vol.  XLVIII.  p.  257.  October  1837. 

G.  Valentin  uber  die  Dicke  der  varicosen  Faden  in  dem  Gehim  und  dem  Rucken- 
mark  des  Menschen.  In  Muller’s  Archiv.  1834.  §401-410. 

S 


274 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


The  sources  from  which  the  brain  derives  its  blood  are  well 
known.  It  is  highly  vascular  throughout.  These  vessels,  first 
divided  in  the  productions  of  the  jna  mater^  are  afterwards  subdi- 
vided to  an  incredible  degree  of  minuteness,  in  the  substance  of 
the  organ.  They  never  anastomose.  (Home.)  They  are  accom- 
panied with  very  minute  veins,  provided,  it  is  said,  with  valves. 
Of  these  the  most  delicate  branches  are  found,  according  to  Sir 
Everard  Home,  in  the  gray  convoluted  matter,  contrary  to  the 
statements  of  Ruysch,  Albinus,  and  others  ; and  conversely  in  the 
white  matter  they  are  much  larger.* 

The  substance  of  brain  has  been  examined  by  several  chemists  ; 
but  the  analysis  most  to  be  trusted,  is  perhaps  that  of  Vauquelin, 
who  found  that  100  parts  of  cerebral  substance  consist  of  80  of 
water,  7 of  albumen,  4.43  of  a white  adipose  matter,  0.70  of  a red 
adipose  matter,  1.12  of  osmazome,  1.5  of  phosphorus,  and  5.15  of 
acids,  salts,  and  sulphur.  Upon  the  presence  of  the  albuminous 
matter  depends  the  solidification  which  the  brain  undergoes  when 
immersed  in  alcohol,  acids,  or  solutions  of  the  metallic  salts,  which 
coagulate  that  substance.  Upon  the  presence  of  the  white  adipose 
matter  depends  the  formation  of  those  brilliant  white  crystalline 
plates,  resembling cholesterine,  observed  by  M.  Gmelin  in  the  brains 
preserved  in  the  anatomical  cabinet  of  Heidelberg.f  The  opinion 
of  this  physician,  that  it  pre-exists  in  the  brain,  in  the  form  of  the 
adipocerous  or  cholesterine  matter  (waxy  brain-fat,)  is  improbable, 
and  requires  more  decisive  experiments  than  those  on  which  he  has 
founded  it. 

The  development  and  growth  of  this  organ  was,  in  1816,  in- 
vestigated with  much  care  by  Tiedemann,  who  has  ascertained  the 
following  points.  In  the  embryo  of  six  weeks,  the  spinal  chord  is 
represented  by  a flat  long  substance,  the  upper  end  of  which  is 
slightly  enlarged.  In  the  second  month,  when  the  brain  is  little 
developed  compared  with  the  spinal  chord,  it  may  be  said  to  con- 
sist, 1st,  of  a cerebellum,  with  considerable  transverse  extent ; 2J, 
of  brain  proper,  exceedingly  small ; 3rf,  of  a third  portion  placed 

G.  R.  Treviranus  Beitrage  zur  Aufkiarung  der  Erscheinungen  und  Gesetze  der  Or- 
ganischen  Lebens  Band  I.  Heft.  II.  183(>-  8,  § 24.  H.  und  Heft.  IV.  1836. 

E.  II.  Weber  in  Schmidt’s  Jahrbuchern  der  in-und-auslandischen  Medicin.  Bd.  XX. 
§ 5.  und  Henle  ebendaselbst.  § 339. 

* Philosophical  Transactions,  Lond.  1821,  pp.  29  and  30. 

t Zeitscrift  fiir  Physiologie,  Von  Tiedemann,  Treviranus,  und  L.  C.  Treviranus, 
Band  I.  1 Heft,  1824. 


3 


BRAIN. 


275 


between  these  two,  and  the  size  of  which  exceeds  that  of  the  brain. 
This  third  portion  corresponds  to  the  protuberance,  or  rather  to 
that  part  of  the  organ,  the  upper  surface  of  which  is  formed  by  the 
four  eminences,  (^corpora  quadrigeminal  and  the  lower  surface  by 
the  annular  protuberance.*  According  to  ]\I.  Serres,  it  is  formed 
in  man  and  animals  before  the  brain  and  cerebellum,  and  imme- 
diately after  the  spinal  chord.  In  the  fifth  month  the  brain  covers 
a part  of  the  protuberance ; it  advances  to  the  cerebellum,  and  in 
the  seventh  exceeds  it.  At  the  same  time,  the  other  parts,  and 
especially  that,  which  we  have  mentioned,  as  the  third  or  central 
portion,  do  not  grow  at  the  same  rate. 

At  the  beginning,  that  is  about  the  seventh  week,  the  brain  is 
found  to  be  divided  in  two  portions  by  a longitudinal  fissure.  Each 
half  mutually  approaches  as  growth  continues,  and  are  at  length 
united,  so  that  at  the  third  month  the  only  parts  found  separate  are 
the  middle  ventricle,  the  aqueduct  or  canal,  which  is  at  this  time  a 
large  cavity  continuous  with  it,  and  the  fourth  ventricle.  The  de- 
velopment of  the  cavities  called  lateral  ventricles  is  closely  connect- 
ed with  that  of  the  contiguous  parts  of  the  organ.  These  appear 
nearly  in  the  following  order. 

The  lateral  lobes  appear  first  about  three  months  after  concep- 
tion ; and  about  the  same  time  the  mesolobe,  {corpus  callosum,)  is 
formed  by  union  of  the  hemispheres;  and  the  cylindroid processes, 
{cornua  ammonis,)  Ywli,  {fornix,)  mammillary  eminences,  posterior 
commissure,  and  cerebral  limbs  or  peduncles,  may  be  recognized. 
Shortly  after  may  be  seen  the  ergot,  or  small  hippocampus,  and  the 
anfractuosity  from  which  it  issues,  and  the  conarium  and  its  pe- 
duncles ; then  the  anterior  commissure,  the  thin  partition  {septum 
lucidum)  and  its  cavity,  which  at  this  time  communicates  with  the 
middle  ventricle ; lastly,  the  semicircular  fillet,  {taenia  semicircula- 
ris,)  and  the  infundibulum,  which  correspond  to  the  seventh  month ; 
and  about  the  same  time  the  outer  surface  of  the  brain  begins  to 
present  the  eminences  denominated  convolutions,  and  the  cerebel- 
lum its  laminated  or  foliated  appearance. 

In  the  early  weeks  of  existence  the  brain  is  fluid,  soft,  and  homo- 
geneous. The  white  matter  and  its  fibrous  structure  is  first  seen ; 
and  the  cross  structure  of  the  fibres  of  the  pyramids  are  observable 
about  the  eighth  week,  according  to  I^I.  Serres.  About  the  sixth 
month  the  cerebral  substance  appears,  when  microscopically  exa- 

* Anatomie  und  Bildungs-Geschichte  des  Gehinis  im  Foetus  des  Menschen  u.  3.  f. 
Von  Dr  Fredrich  Tiedemann,  Professor  der  Anatomie,  u.  s.  f.  Nurnberg,  1816,  4to. 


276 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


mined,  to  consist  of  globules  immediately  beneath  the  pia  mater, 
and  of  fibres  at  a greater  depth.  In  the  seventh  month  a section 
of  the  ventricles  shows  very  distinct  layers  of  radiating  fibres.  Af- 
ter these  are  seen  new  ones,  which  form  convolutions,  and  which 
are  termed  converging  fibres.  At  the  ninth  month  the  organiza- 
tion is  complete. 

The  gray  substance  appears  a long  time  after  the  white.  At 
the  end  of  the  sixth  or  seventh  month  this  substance  is  formed  in 
the  olivary  eminences,  which  then  assume  their  proper  appearance ; 
about  the  end  of  gestation  the  spinal  chord  is  also  filled  with  gray 
matter,  and  about  the  ninth  month  this  substance  is  distinctly  seen 
in  the  convolutions,  the  plates  of  the  cerebellum,  &c.  These  re- 
sults are  much  like  those  of  Serres,  unless  as  to  what  regards  the 
brain  proper,  in  which,  according  to  this  anatomist,  the  optic  cham- 
bers and  striated  bodies  consist  originally  of  gray  substance  entirely, 
to  which  white  cerebral  matter  is  afterwards  added. 

Of  the  process  of  growth,  the  principal,  indeed  the  sole  agent  is 
the  vascular  membrane ; (meninx  tenuis,  pia  mater  et  plexus  cho- 
roides:  das  Geffasshaut. ) The  two  divisions  of  this,  viz.  the  ex- 
ternal, or  that  belonging  to  the  convoluted  surface,  and  the  inter- 
nal, or  that  pertaining  to  the  figurate,  may  be  distinguished  pre- 
vious to  the  formation  of  any  part  of  the  brain,  and  when  the  two 
portions,  which  are  afterwards  destined  to  be  separate,  are  the 
same,  and  indistinguishable  from  each  other.  The  formation  of 
the  organ  appears  to  commence  at  once  upon  two  orders  of  vessels 
mutually  looking  towards  each  other;  that  which  is  to  be  the  cen- 
tral (^plexus  choroides)  being  merely  a mesh  of  vessels  looking  to 
that  which  is  to  be  peripheral,  {pia  mater.)  The  first  portions  of 
newly  deposited  cerebral  matter  form  the  barrier  between  these 
extremities,  which  continue  to  be  more  widely  parted,  as  the  process 
of  development  advances.  This  membrane  is  then  more  vascular 
than  at  any  subsequent  period.  The  cerebral  matter  is  first  depo- 
sited soft,  and  firmly  adherent  to  these  vessels,  which  are  ramified 
in  every  direction  through  its  substance.  It  becomes  firmer  after- 
wards and  less  vascular  the  longer  the  period  from  deposition. 
Hence  the  two  surfaces,  the  outer  and  inner,  are  much  softer  and 
more  pulpy,  and  more  firmly  attached  to  the  vessels,  than  the  in- 
termediate deep  matter.  Tiedemann  appears  to  regard  the  process 
of  development  as  proceeding  from  the  centre  to  the  circumference. 
This  is  correct,  but  not  in  the  exact  sense  in  which  he  understands 
it.  The  centre  is  not  in  this  case  the  figurate  surface  of  the 


BRAIN. 


277 


brain,  but  tbe  centre  of  the  optic  and  striated  bodies  which  is  first 
deposited,  and  from  which  the  process  of  deposition  advances 
to  both  surfaces  at  the  same  time,  and  nearly  at  equal  rates. 
These  inferences  are  established  by  the  phenomena  observed  in  the 
development  of  the  organ  in  the  young  of  mammiferous  animals  in 
general. 

Section  II. 

Cerebral  substance  is  liable  to  inflammation,  acute  and  chronic, 
to  hemorrhage,  to  eflPusions  of  serous  fluid,  to  alterations  in  its  na- 
tural consistence,  and  to  tumours. 

Encephalia  Acuta ; Encephalitis.  (Frank,  Costantin.)  Acute 
inflammation  of  the  brain  is  a rare  disease,  and,  perhaps,  if  always 
carefully  investigated,  would  be  found  never  to  take  place  sponta- 
neously or  primarily.  As  the  effect  of  accidental  violence,  and  the 
result  of  morbid  poisons,  it  is  much  more  frequent ; and  it  is  chief- 
ly under  such  circumstances  that  its  phenomena  and  effects  are 
known.  (Pott,  Dease,  Hill,  Malacarne,  Desault,  J.  Bell,  M.  A. 
Petit,  O’Halloran,  Aberuethy.)  As  the  effect  of  mechanical  in- 
jury, the  disease  is  found  to  be  generally  circumscribed.  Part  of 
the  brain  becomes  very  vascular,  acquires  a red  colour  of  various 
shades  of  intensity,  and  eventually  becomes  brownish  or  green,  and 
much  softer  than  natural.  The  formation  of  matter  in  a distinct 
cavity  appears  not  so  common  in  this  form  of  the  disease  as  in 
another,  which  I am  soon  to  mention.  An  abscess  is  not  very  fre- 
quently remarked  under  such  circumstances,  unless  when  a foreign 
body,  as  a bullet,  a stone,  or  a piece  of  bone  has  been  di’iven  into 
the  brain.  This  process  gives  rise  to  intense  headach,  delirium, 
and  intolerance  of  light,  quickly  succeeded  by  convulsions,  coma, 
and  death. 

Of  the  effect  of  morbid  poisons  in  inducing  cerebral  inflam- 
mation more  or  less  acute,  an  example  is  found  in  the  severe 
form  of  fever  prevalent  in  jails  and  camps.  In  several  examples 
of  this  disease  abscesses  of  the  brain  have  been  found,  (Pringle) ; 
and  it  is  often  possible  to  trace  the  process  from  the  flrst  marks  of 
injection  to  the  complete  formation  of  purulent  matter. 

2.  Encephalia  Suhacuta.  (Pulpy  destruction ; ramollissement, 
Rostan,  Lallemand,  &c.)  Subacute  or  chronic  inflammation  of  the 
brain  is  greatly  more  common.  Its  anatomical  characters  are  much 
the  same  as  those  of  the  acute  form ; but  the  longer  duration  of  the 
process  gives  rise  to  modifications  which  the  pathologist  should  dis- 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


tinguisli.  At  first  a part  of  the  brain  becomes  more  or  less  red 
and  vascular.  As  this  goes  on,  it  passes  successively  into  crimson, 
violet  or  purple,  brown,  or  claret  colour,  while  the  consistence  of 
the  part  is  much  diminished.  A shade  of  green  announces  the 
formation  of  purulent  fluid ; and  in  proportion  as  this  process  con- 
tinues before  life  is  extinct,  the  part  becomes  yellow,  or  gray,  or 
grayish  brown,  (suhfusca)  very  soft  and  pulpy,  or  even  semifluid. 
It  is  perhaps  equally  rare  in  this  as  in  the  former  case,  to  find  per- 
fect purulent  matter  in  a distinct  cavity.  This  change,  which  is 
often  mentioned  by  Morgagni,*  is  one  form  of  the  disease  describ- 
ed by  Rostan  f and  Lallemand,:j:  under  the  name  of  softening  (ra- 
mollissement)  of  the  brain,  and  since  that  time  by  Bouillaud, 
Bright,  Durand-Fardel,  and  other  authors.  The  softening  is  a 
mere  effect  of  the  process  of  inflammation,  subacute  or  chronic.  In 
some  instances  the  softening  is  attended  with  effusion  of  serous 
fluid,  without  much  discoloration  of  the  part. 

Subacute  or  chronic  inflammation,  terminating  in  softening  of 
the  brain,  may  take  place  either  on  the  convoluted  surface  of  the 
organ,  wdien  it  generally  occupies  an  extent  of  two  or  three  square 
inches ; or  at  the  figurate  surface,  when  it  is  most  common  on  the 
middle  portion,  (^septum  lucidum^  and  extending  along  the  twain- 
band  ; or  in  the  substance  of  the  organ,  when  it  affects  most  fre- 
quently the  striated  bodies,  the  optie  thalami,  the  central  part  of 
the  hemispheres,  the  cerebellum,  and  the  cerebral  prolongations, 
(crura  cerebri^  in  the  order  now  enumerated.  Its  occurrence  in 
the  spinal  chord,  in  which  the  same  series,  of  changes  takes  place, 
has  been  described  by  M.  Pinel  the  younger, § M.  Olivier,  ||  and 
M.  Velpeau.^ 

What  is  the  intimate  nature  of  this  disease,  and  wherein  does  it 

■*  Epistola,  V.  6,  7.  IX.  16,  18,  19.  In  the  brain  of  Marchetti,  the  anatomist, 
who,  after  two  epileptic  attacks,  died  apoplectic,  the  gray  matter  was  so  tender,  that 
on  the  slightest  touch  it  was  converted  into  a fluid  substance,  as  if  it  never  had  co. 
hered. — L.  vii.  14,  15. 

-|-  Recherches  sur  une  maladie  encore  peu  connue,  qui  a refu  le  nom  de  ramollisse- 
ment  du  Cerveau.  Par  L.  N.  Rostan,  Medecin  de  la  Salpetriere,  &c.  A.  Paris,  1820. 

J Recherches  Anatomico-Pathologiques  sur  I’Encephale,  et  ses  dependances.  Par 
F.  Lallemand,  Prof,  de  Clinique,  &c.  Paris,  1820-1821. 

§ Sur  ITnflammation  de  la  Moelle  Epiniere.  By  AI.  Pinel,  Fils.  Journal  de  Phy- 
siologie  Experimentale,  Vol.  li.  p.  54. 

II  De  la  Moelle  Epiniere  et  de  ses  Maladies.  Par  C.  P.  Ollivier.  Paris,  1824. 

^ Memoire  sur  une  Alteration  de  la  Moelle  Allong^e,  &c.  Par  M.  A.  I'’elpeau. 
Archives  Generales,  Tome  VII.  p.  52  and  329.  Paris,  1825. 


BRAIN. 


279 


differ  from  suppuration  of  tfie  organ  ? This  question  must  be  de- 
termined by  considering  the  anatomical  characters  of  the  lesion, 
and  the  circumstances  under  which  it  takes  place.  In  the  part  af- 
fected, the  portion  of  brain  is  never  entirely  removed.  The- cere- 
bral substance  is  separated,  broken  down,  and  mixed  either  with 
serous,  with  bloody,  or  with  purulent  fluid. 

It  may  succeed  at  least  four  morbid  states  of  the  organ.  1.  It 
may  be  the  consequence  of  the  blood-stroke,  {coup  de  sang,)  or  in- 
jection of  the  vessels  of  a given  region  of  the  organ.  The  softened 
part  is  then  reddish,  rose-coloured,  amaranth,  crimson,  or  brown. 
2.  It  may  follow  the  effusion  of  x’ed  blood,  which  nearly  in  the 
same  manner  separates  and  breaks  down  the  delicate  substance  of 
the  organ  in  which  it  is  effused.  The  softened  portion  is  then  ge- 
nerally brown,  or  a wine-lee  colour  ; but  if  a considerable  time  has 
elapsed  after  effusion,  it  may  be  of  a dirty  or  ashy  colour,  tending 
to  green,  and  not  unlike  softened  bread.  3.  It  may  either  accom- 
pany or  follow  the  process  which  terminates  in  hydrocephalic  effu- 
sion. It  is  then  of  a milk-white  colour.  (Rostan,  Lallemand.) 
4.  It  may  take  place  in  the  cerebral  substance  surrounding  tu- 
mours, (Meckel,  Blane,  Powell,  &c.)  when  its  colour  varies  from 
pale-red  to  green,  yellow,  and  brown. 

From  these  facts  it  may  be  inferred,  that  softening,  or  pidpg 
disorganization  of  the  brain  is  not  so  much  a proper  disease  as  the 
effect  of  a morbid  process,  which  takes  place  in  different  conditions 
of  the  brain. 

When  it  occurs  in  the  first  manner,  it  is  the  result  of  a species 
of  diffuse  inflammation,  in  which  there  is  no  tendency  to  limit  the 
action  of  the  disease  by  the  effusion  of  lymph,  or  the  formation  of 
a vascular  cyst.  This  is  well  illustrated  in  those  cases  recorded  by 
Morgagni,  in  which  parts  of  the  brain  had  become  yellowish  or 
greenish,  with  much  diminution  of  consistence,  (Epist.  lii.  2.  ix.  20. 
XXV.  10.  lii.  23) ; and  in  the  eighth  delineation  of  Dr  Hooper, 
(p.  23.)  In  cases  of  this  description,  a sero-albuminous  or  semi- 
purulent  fluid  is  infiltrated  into  the  cerebral  substance,  portions  of 
which  are  thus  separated  and  detached  from  each  other.  The  pro- 
cess is  allied  to  inflammation ; but  it  is  an  abortive  form,  in  so  far 
as  it  fails  to  concentrate  the  action  to  a definite  spot. 

That  it  takes  place  in  the  inflammatory  or  disorganizing  process 
which  succeeds  mechanical  injury  is  established  by  the  necrological 
appearances  found  in  the  brain  in  such  circumstances.  (Fantoni, 


280 


GENERAL  AND  PATHOLOGICAL  ANATOMY, 


Morgagni,  Louis,  Le  Dran,  Schmucker,  O’Halloran,  Lease,  Aber- 
nethy,  Thomson,  Hennen,  &c.) 

When  softening  takes  place  in  connection  with  serous  effusion, 
it  is  partly  the  concurrent  effect  of  inflammation,  partly  of  the  ef- 
fused fluid.  This  is  well  illustrated  in  those  cases  in  which  the 
septum  lucidum  is  attenuated,  reticular,  and  perforated,  or  at  length 
ruptured.  This  form  of  destruction,  accompanied  with  more  or  less 
softening  of  the  twain-band,  (fornix ),  is  repeatedly  mentioned  by 
Morgagni,  and  has  been  noticed  by  most  authors  who  have  described 
cases  of  watery  effusion  within  the  cerebral  cavities.  I have  seen  it 
in  three  sorts  of  cases ; first,  in  the  true  hydrocephalic  effusion ; 
secondly,  in  that  which  takes  place  in  continued  fever;  and,  thirdly, 
in  the  course  of  chronic  meningeal  inflammation,  with  thickening 
of  the  dura  mater ^ after  injury. 

Not  only  does  pulpy  disorganization  occur  in  this  part  of  the 
organ  in  continued  fever,  but  it  takes  place  in  the  substance  of  the 
hemispheres.  Of  this  pathological  fact  good  instances  are  given  by 
Jemina,  as  they  occurred  in  an  epidemic  at  Montreal,  in  the  terri- 
tory of  Turin,  in  1783-84.  In  one  the  white  matter  of  the  hemi- 
sphere {centrum  ovale)  was  soft,  pulpy,  (fracidum,)  of  an  ash-colour, 
passing  into  yellow,  and  pasty ; in  another  it  was  soft  and  tawny- 
coloured,  like  spoilt  fruit ; and  in  a third  the  cerebellum  was  simi- 
larly cbanged.*  The  same  change  was  observed  by  Dr  Black  of 
Newry  in  the  cerebral  hemisphere.  (Transactions,  Vol.  II.) 

When  pulpy  disorganization  is  connected  with  effusion  of  blood, 
it  has  been  supposed  by  M.  Rostan  to  be  the  cause  of  that  effusion. 
That  this  supposition  is  inadmissible,  I infer  from  the  following 
facts,  which  I have  witnessed  more  than  once.  Lf,  That  the  por- 
tion of  brain  inclosing  the  clot  is  soft  and  pulpy  all  round,  but 
sound  in  proportion  to  the  distance  from  the  clot.  2fZ,  That  in 
some  instances  in  which  partial  recovery  takes  place,  part  of  the 
red  clot  has  disappeared,  and  its  place  is  supplied  by  serous  fluid. 
3rf,  That  in  cases  in  which  death  takes  place  early,  the  pulpy  dis- 
organization is  less  complete  than  those  in  which  it  takes  place  at 
a later  period.  In  short,  the  extent  of  the  disorganization  is  pro- 
portionate to  the  interval  which  elapses  between  the  effusion  of  the 
blood  and  the  period  of  death. 

When  pulpy  disorganization  accompanies  tumours  of  the  brain, 

* De  Febre,  Anno  1783-84,  Monteregali  Epidemica,  auctore  Marco  Antonio  Jemina, 
M.  D.  &c.  Extat  in  Brera  Sylloge,  Vol.  X.  p.  218,  247. 


4 


BKAIN. 


281 


that  it  is  the  effect  of  the  presence  of  these  tumours,  and  the  chronic 
congestion  which  they  cause,  is  sufficiently  obvious  to  render  super- 
fluous any  minute  induction.  It  is  enough  to  say,  that,  though  not 
constant,  it  is  a very  general  effect.  (Morgagni,  Meckel,  Sandi- 
fort,  Powell,  Yellowly,  Plane,  &c.) 

The  morbid  change  now  described  was  supposed  by  Morgagni 
and  Lieutaud,  to  the  former  of  whom  it  was  well  known,  to  be  of 
the  nature  of  gangrene  in  other  parts.  This  idea,  which  is  also 
that  of  Jemina*  and  of  Baillie,  has  been  revived  by  Dr  Abercrom- 
bie.f  Though  unwilling  to  dissent  from  the  opinion  of  a pathologist 
distinguished  for  accurate  induction,  it  appears  to  me  exceedingly 
doubtful,  for  the  reasons  above  stated,  how  far  this  analogy  can  be 
demonstrated. 

A part  of  the  brain  changed  as  above  described  is  indeed  disor- 
ganized, may  be  said  to  be  dead,  and  in  this  sense  the  change  may 
be  termed  gangrene  of  the  brain.  But  when  it  is  found  in  different 
degrees,  and  in  so  many  different  morbid  states  of  the  brain,  some 
of  them  of  long  continuance,  it  is  difficult  to  be  satisfied  that  every 
one  of  them  must  be  viewed  equally  as  gangrene.  In  the  present 
work  I avoid  as  much  as  possible  whatever  is  hypothetical  or  doubt- 
ful. Upon  this  principle  I conceive  it  improper  to  offer,  on  the 
nature  of  this  change,  any  further  opinion  than  can  be  collected 
from  the  circumstances  above  stated  of  its  history  and  connections. 

One  form  of  softening,  nevertheless,  there  is,  which  is  more  justly 
entitled  to  the  character  of  gangrene  than  the  others.  In  a certain 
proportion  of  cases  the  arteries  of  the  brain  become  steatomatous 
and  opaque  and  inelastic,  or  osteo-steatomatous  and  more  or  less 
rigid.  Thus  the  Sylvian  artery  or  its  branches,  the  basilar  artery 
or  its  branches,  the  posterior  and  middle  cerebral,  and  the  cerehellic, 
may  all  be  affected  with  this  transformation.  In  such  circumstances, 
it  is  observed  that  softening  comes  on  very  suddenly,  and,  apparently 
without  any  preliminary  inflammatory  or  hemorrhagic  stage,  pro- 
ceeds instantly  or  speedily  to  complete  brown  or  green-coloured 
disorganization  of  a portion  of  the  brain.  The  entire  duration  of 
this  form  of  softening  seldom  exceeds  three  or  four  days.  It  is 

* “ Aliud  etiam  ex  hoc  morbo  defuncti  caput  aperui  ; et  memini  inter  ceetera  ob- 
servata  substantiae  cerebri  pulposae  portionem  magnitudine  nucis’  avellanae,  colore,  et 
consistentia  vitiatam,  ita  ut  esset  coloris  tane  et  mollior,  non  secus  ac  poma  vel  pyra 
cum  intus  marcescere  incipiunt.  Annon  gangraena  hujus  visceris  ? De  Febre,  anriis 
1783-84.  MonteregaU  Epidemica,  auctore  Marco  Antonio  Jemina,  M.  D.  &c.  Apud 
Brera  Syllogen,  Tom.  X.  p.  247. 

t Pathological  and  Practical  Researches,  p.  ‘25. 


282 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


most  common  in  the  corpus  striatum,  or  that  and  the  optic  thala- 
mus^ and  in  the  crura  of  the  brain, 

Tliis  aifection  resembles  in  some  respects  gangrene  of  a member 
from  disease  and  obstruction  of  its  arteries. 

Pulpy  softening  presents  different  characters  in  different  regions 
of  the  brain.  On  the  convoluted  surface  in  many  brains  there  are 
seen  depressed  orange-coloured  spots  about  the  size  of  a split  pea, 
and  sometimes  larger.  These  spots,  which  are  slightly  depressed 
or  hollow,  are  the  remains  of  previous  attacks  of  softening  affecting 
the  convoluted  surface.  In  some  instances,  especially  where  they 
have  succeeded  injury  or  violence  inflicted  on  the  skull,  they  are 
more  extensive  and  deeper ; and,  while  the  depressed  surface  is  of 
the  orange-colour,  it  is  also  softened,  pulpy,  not  presenting  the 
usual  structure  ; and  there  has  been  a manifest  loss  of  substance. 

Persons,  in  whose  brains  these  appearances  are  observed,  are 
unsteady  or  tottering  in  gait,  paralytic,  and  speak  inarticulately  and 
thick.  Their  memory  is  feeble,  sometimes  greatly  impaired ; their  in- 
tellect is  sometimes  disordered ; and  in  certain  cases  they  are  fatuous. 

When  softening  affects  the  central  portions  of  the  brain,  it  con- 
verts them  into  a soft,  white,  cream-like  substance.  The  fornix  is 
either  much  softened  or  destroyed ; its  posterior  and  lateral  limbs 
are  softened ; the  septum  lucidum  is  perforated  by  many  holes,  or 
completely  broken  down,  and  converted  into  one  large  aperture. 

When  softening  affects  either  of  the  corpora  striata  or  ojdic  tha- 
lami.,  it  usually  assumes  the  reddish-brown  colour,  showing  that 
there  had  been  effusion  of  blood ; and  sometimes  the  reddish-brown 
is  mixed  with  yellow,  or  greenish-yellow  softening,  or  the  wine-lee 
softening  passes  into  the  greenish-coloured  softening,  showing  that 
blood  had  been  effused,  and  that  suppuration  was  proceeding. 

Lastly,  in  either  of  the  crura,  softening  is  commonly  what  is 
called  hortensia-red,  that  is,  of  the  deep  crimson  imitating  the  co- 
lour of  the  flower  of  the  hortensia ; in  short,  it  is  blood  recently 
effused,  breaking  down  and  mixed  with  the  cerebral  matter.  The 
reason  of  this  is,  that  hemorrhagic  softening  in  the  crura  is  in  ge- 
neral speedily  fatal,  that  is,  it  is  followed  by  death  within  three  or 
four  days,  and  the  life  of  the  individual  is  rarely  prolonged  to  the 
sixth  day. 

Hemorrhage  within  the  substance  of  the  protuberance  is  still 
more  rapidly  fatal ; and  in  that  body  accordingly  softening,  pro- 
perly so  called,  is  almost  never  seen. 

Lastly,  it  is  proper  to  observe,  that,  in  a large  proportion  of 


BRAIN. 


283 


cases,  softening  of  the  brain  is  preceded  by  the  steatomatons  or 
osteo-steatomatous  degeneration  of  the  cerebral  arteries,  which  are 
either  specked,  or  opaque,  or  rigid  and  brittle,  and  by  an  unsound 
and  irregular  state  of  the  circulation  within  these  vessels. 

The  effects  of  this  disease  on  the  system  are  not  very  well  dis- 
tinguished. They  may  be  divided  into  common  and  proper.  The 
common  eflFects  are  dull  pain,  or  sense  of  weight  in  the  head,  dull- 
ness, impaired  memory,  frequent  drowsiness,  and  occasional  peevish- 
ness at  trifles,  and  paralytic  affections  of  the  face,  head,  and  mem- 
bers. The  proper  efiects  are  sense  of  formication,  numbness,  and 
rigidity,  or  occasional  involuntary  contractions  of  the  muscles  of  the 
upper  extremities,  followed  by  delirium  or  fatuity,  and  a peculiar 
odour  about  the  head,  not  dissimilar  to  that  of  the  mouse.  In  the 
spinal  chord  it  gives  rise  to  numbness  and  rigid  contraction  of  the 
muscles  of  the  lower  extremities,  and  eventually  palsy  more  or  less 
complete. 

These  symptoms,  which  are  chiefly  those  given  by  the  French 
authors  already  mentioned,  apply  to  the  acute  form  of  the  disease.* * * * 
In  more  chronic  states  it  seems  not  to  affect  the  muscular  motions 
considerably,  but  rather  to  induce  fatuity  and  other  forms  of  im- 
paired intellect.  This  inference  at  least  results  from  some  of  the 
observations  of  Morgagni,*  and  those  of  Dr  John  Hunter.f  This 
is  the  state  of  brain  which  tabes  place  in  cases  of  fatuity  succeeding 
coup-de-soleil. 

3.  Suppurative  Inflammation,  Apostema  Cerebri.  Collections  of 
purulent  matter  have  been  often  found  in  the  substance  of  the  brain. 
That  these  collections  may  take  place  spontaneously,  as  a conse- 
quence of  previous  inflammation,  is  established  by  the  testimony  of 
Morgagni,^  Lieutaud,§  Baader,||  Baillie,^' Powell,** * * §§  Brodie,ft  Hoo- 
per,JJ  and  Abercrombie. §§  Of  the  observations  of  these  authors 
the  result  is,  that,  though  a collection  of  purulent  fluid  to  a greater 

* Epist.  viii.  .|-  Apud  Baillie,  Morbid  Anatomy. 

+ Epistola  V.  § Historia  Anatomico-Medica. 

11  Joseph!  Baader,  Observat.  Med.  Obs.  22.  Extat  apud  Sandifort  Thesaurum 
Vol.  III.  p.  28. 

^ Engi-avings  to  illustrate  the  Morbid  Anatomy,  &c.  X.  Fasciculus,  Plate  vi.  p.  221 

**  Some  Cases  illustrative  of  the  Pathology  of  the  Brain.  By  Richard  Powell,  M.  d! 
Transactions  of  the  College  of  Physicians,  Vol.  V.  p.  198,  Case  6 and  8. 

tt  Case  of  Abscess  in  the  Brain.  By  B.  C.  Brodie,  Esq.,  F.  R.  S.,  &c.  Transactions 
of  a Society,  Vol.  III.  p.  106. 

it  The  hlorbid  Anatomy  of  the  Human  Brain.  Bv  Robert  Hooper,  M.  D.  London 
1826.  Plate  ix.  p.  25.  ' ’ 

§§  Abercrombie,  Cases  31,  32,  33,  and  34. 


284 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


or  less  extent  may  take  place  in  either  of  the  hemispheres,  and  in 
almost  any  part  of  these  hemispheres,  its  situation  is  influenced 
much  by  the  kind  of  abscess.  The  ordinary  abscess,  consisting  of 
an  irregular  cavity  containing  purulent  matter,  sometimes  mixed 
with  flakes  of  lymph,  and  rendering  it  curdly,  may  take  place  either 
in  the  anterior  lobe  (J.  Earle,* * * §  Hooper,)  or  in  the  centre  of  the 
hemisphere  (Chizeau,f  Baillie).  An  abscess,  consisting  of  several 
small  communicating  cavities,  takes  place  in  the  anterior  lobe,  and 
occasionally  in  the  substance  or  in  the  vicinity  of  the  striated  nu- 
cleus of  Reil.  The  abscess  consisting  of  a firm  cyst,  containing 
purulent  matter,  is  generally  found  in  the  centre  of  the  hemispheres. 
(Powell,  case  8 ; Hooper,  PI.  9,  Fig.  3 ; Abercrombie,  cases  16, 
17.) 

Collections  of  purulent  matter  have  been  found  in  the  lobes  of 
the  cerebellum  by  Bianchi,J  (often  Latinized  Janus  Plancus,) 
Stoll,§  Weikard,||  and  Abercrombie. IF  In  general  they  are  con- 
tained in  a cyst  more  or  less  distinct,  the  walls  of  which  are  mem- 
4)ranous  and  vascular.  In  the  case  of  Weikard  he  represents  the 
whole  white  matter  almost  of  the  left  lobe  to  be  converted  into  a 
millet-like,  something  foul,  purulent  matter,  by  which  I understand 
it  to  have  been  flocculent  and  lymphy.  Suppuration,  less  distinctly 
defined,  and  deposited  generally  in  small  irregular  cavities,  takes 
place  in  the  medulla  oblongata^  especially  in  that  part  of  the  olivary 
body  which  contains  the  corpus  dentatum.  Abercrombie  mentions 
a case  at  the  junction  of  the  protuberance  (39.)  In  the  chord  itself, 
though  more  rare,  and  generally  confined  to  the  surface,  yet  it  has 
been  seen  in  the  form  of  infiltration  by  Brera  ;**  and  in  a distinct 
cavity  in  the  cervical  portion  by  Velpeau.ft 

The  origin  of  these  collections  is  not  well  known.  That  they 
are  the  result  of  a form  of  inflammation  cannot  be  denied ; but  that 
it  is  not  ordinary  inflammation,  is  to  be  inferred  from  the 
slow  progress  which  they  generally  observe,  and  from  the  vari- 

* Med.  and  Phys.  Journal,  Vol.  XXTIl.  p.  89. 

-]-  Recueil  Periodique,  No.  xxxiv. 

if  Giovan.  Bianchi  Storia  d’un  Apostema  nel  lobo  destro  del  Cerebello.  Rimini, 
1751.  And  Jani  Planci  Storia,  d’un  Apostema  nel  Cerebello.  Rimini,  1752. 

§ Maximil.  Stoll  Rationis  Medendi,  Pars  i.  178,  et  iii.  159. 

II  Vermischte  Scbriften  von  M.  A.  Weikard  fiirstl.  Fuldisch  Leibartz.  Frankfort 
am  Main,  1782.  Viertes  St.  p.  74. 

K Pathological  and  Practical  Researches,  case  iii.  and  xl. 

**  Cenni  sulla  Rachitide. 

TT  Revue  Medical,  1826. 


BRALV. 


285 


able  effects  to  which  they  give  rise.  They  are  said  in  general  to 
be  connected  with  the  strumous  diathesis ; and  they  are  most  com- 
monly found  in  subjects  who  present  the  usual  marks  of  this  dia- 
thesis. This,  however,  is  only  expressing,  in  different  terms,  an 
obscure  fact,  the  real  cause  of  which  is  quite  unknown.  The  en- 
cysted abscess,  especially  that  such  as  is  delineated  by  Dr  Hooper, 
is  of  the  kind  called  by  old  pathologists  abscess  by  congestion^  or 
cold  abscess. 

One  form  of  suppuration  of  the  brain  I think  there  is  strong  rea- 
son to  believe  depends  on  the  presence  of  previous  disease,  inflamma- 
tory, suppurative,  or  gangrenous,  in  the  lungs,  and  probably  in  other 
organs.  This  is  when  suppuration  takes  place  in  the  brain,  either 
in  one  abscess,  or  diffusely,  or  in  the  sinuses  of  the  brain  after  sup- 
puration or  gangrene  of  the  lungs.  This  connection  was  observed 
in  the  two  following  cases. 

In  the  summer  of  1836,  I was  requested  to  see  a child  of  about 
two  years,  labouring  under  apparent  affection  of  the  brain.  Symp- 
toms of  this  I indeed  observed  in  the  heat  of  the  head,  the  restless- 
ness, the  spasmodic  movements  of  the  eyes,  a little  enlargement  of 
the  head,  constant  tossing  backwards  and  to  each  side,  the  uneasi- 
ness of  the  stomach,  and  the  insensible  state  of  the  intestinal  tube. 
But  besides  these  symptoms,  the  child  was  greatly  emaciated, 
coughed  much,  and  occasionally  expectorated.  There  was  much 
general  feverishness.  On  examining  the  chest,  I found  consider- 
able cavernous  destruction  of  the  upper  lobe  of  the  right  lung,  with 
some  flattening  and  depression  of  the  ribs.  Two  days  afterwards, 
death  took  place,  I found  the  upper  lobe  and  part  of  the  middle 
lobe  of  the  right  lung  hollowed  into  a rugged  cavernous  abscess, 
with  irregular  cavities,  and  walls  covered  with  a little  purulent 
matter,  emitting  an  offensive  odour.  In  the  brain  the  convolutions 
were  much  flattened,  indeed  their  eminences  were  almost  effaced ; a 
little  turbid  sero-purulent  fluid  was  contained  within  the  ventricles ; 
the  longitudinal  sinus,  the  torcular,  the  lateral  sinuses,  and  the  small 
sinuses  at  the  base  were  filled  with  blood  half-coagulated,  and  con- 
taining lymph  and  purulent  matter ; and  even  the  large  veins  of 
the  pia  mater  opening  into  these  sinuses  contained  half-clotted 
blood  and  purulent  matter. 

It  appears  to  me  nearly  certain,  that  the  lymph  and  purulent 
matter  were  conveyed  by  the  veins  of  the  lungs  into  the  circulation, 
and  thence  into  the  venous  canals  of  the  brain. 


286 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


I have  elsewhere  published  in  detail  the  circumstances  of  a case 
of  abscess  in  the  right  hemisphere  of  the  brain,  immediately  on  the 
outsiile  of  the  ventricles,  in  which  this  lesjon  accompanied  or  fol- 
lowed an  attack  of  gangrene  of  the  right  lung.  The  matter  was 
here  contained  within  a distinct  cavity ; was  opaque,  consistent, 
greenish-yellow,  like  well-formed  purulent  matter ; and  the  progress 
of  the  symptoms  had  been  carefully  watched.  The  abscess  was 
about  two  inches  and  a-half  long  antero-posteriorly,  and  one  inch 
broad  transversely,*  and  about  one  inch  at  its  greatest  vertical  depth. 

I am  aware  that  in  both  cases  it  may  be  argued  there  was  merely 
coincidence  in  the  two  circumstances.  And  by  some  it  may  be  even 
said,  that  the  evidence  is  as  strong  for  the  affection  of  the  lungs 
having  followed  that  of  the  brain,  as  the  affection  of  the  brain  fol- 
lowing that  of  the  lungs.  All  this  may  be  correct.  The  main 
point  is  to  remark  the  fact  of  coincidence  or  simultaneous  existence, 
and  the  anatomico-pathological  fact,  that  in  other  instances  the 
veins  appear  to  act  as  the  channels  for  conveying,  through  various 
parts  of  the  human  body,  lymph,  purulent  matter,  and  other  sub- 
stances presented  to  their  orifices. 

One  variety  of  cerebral  abscess,  that  connected  with  discharge 
from  the  ear,  originates  in  a more  obvious  manner.  Purulent  dis- 
charge from  the  ear-hole  is  indeed  generally  connected  with  in- 
flammation, subacute  or  chrouic,  of  the  dura  mater,  or  vascular 
membrane,  or  both ; and  in  some  instances  the  disease  takes  an 
unfavourable  turn  in  this  manner,  and  speedily  proceeds  to  a fatal 
termination.  (Morgagni,  Powell,  case  5 ; Itard,  Duncan  Junior, 
Abercrombie.)  In  other  circumstances,  however,  either  with  or 
without  this  meningeal  inflammation,  a similar  affection  strikes  sud- 
denly a part  of  the  cerebral  substance,  and,  proceeding  rapidly  to 
the  suppurative  stage,  forms  a distinct  cerebral  abscess.  Cases  of 
this  description  were  early  noticed  by  Ballonius,  Gontard,  and 
more  recently  by  an  anonymous  writer ,f  Mr  Brodie,J  Dr  0’Brien,§ 
Mr  Parkinson, |]  and  Dr  Duncan  Junior.^ 

’ Cases  and  Observations  illustrative  of  the  Nature  of  Gangrene  of  the  Lungs.  By 
David  Craigie,  M.  D.,  F.  R.  S.  E.,  &c.  Edin.  Med.  and  Surgical  Journal,  Vol.  LVl. 
p.  1,  case  1. 

t Medical  Commentaries,  II.  180.  The  History  of  a Suppuration  of  the  Brain,  &c. 

X Transactions  of  a Society,  &c.  Vol.  III.  p.  106. 

§ Trans,  of  King  and  Queen’s  Coll.  Dublin,  Vol.  II.  p.  309. 

II  Medical  Repository.  London,  1817. 

^ Edinburgh  Medical  and  Surgical  Journal.  Contributions  to  Morbid  Anatomy, 
No.  ii.  Vol.  XVII.  p.  331.  By  A.  Duncan,  Jun.  M.  D.,  &c.  Cases  4th,  5th,  and  6th. 


BRAIN. 


287 


By  Bonetus  this  atFection  of  the  cerebral  substance  was  believed 
to  precede  and  to  cause  the  discharge  from  the  ear.  Although  this 
idea  was  refuted  by  Morgagni,  who  regards  the  cerebral  abscess 
as  consecutive  to  the  ear-discharge,  especially  its  suppression,  it  has 
been  revived  by  Mr  Brodie,  who  seems  to  think  the  affection  of  the 
brain  coeval  with  that  of  the  ear.  I shall  afterwards  show  that  the 
internal  affection,  to  which  Bonetus  and  Mr  Brodie  ascribe  this 
character,  and  which  they  think  causes  the  ear-discharge,  is  disease 
either  of  the  tympanal  cavity,  or  of  the  dura  mater  investing  the 
temporal  bone.  The  inflammation  which  terminates  in  abscess  of 
the  cerebral  substance  is  the  effect  of  inflammation  of  the  mem- 
branes, and  in  some  instances  of  the  discharge  being  suddenly 
checked,  and  the  chronic  external  inflammation  being  suddenly  con- 
verted into  an  acute  internal  disease.  Is^,  It  is  generally  remarked 
to  succeed  quickly  the  suppression  or  the  disappearance  of  the  ex- 
ternal discharge.  This,  which  was  the  opinion  of  Morgagni,  is 
proved  by  the  cases  of  Mr  Brodie,  Mr  Parkinson,  Dr  O’Brien,  and 
Dr  Duncan.  2fZ,  That  it  does  not  exist  from  the  origin  of  the 
discharge  may  be  inferred  when  the  patient  is  suddenly  attacked 
with  acute  deep  pain  in  the  head,  intolerance  of  sound,  and  deli- 
rium, quickly  followed  by  insensibility  and  coma.  Zd,  It  is  impro- 
bable that  a disease,  commencing  with  the  acute  symptoms  to 
which  the  formation  of  this  abscess  can  generally  be  traced,  should 
be  going  on  for  years  without  deranging  more  considerably  the 
faculties  of  sensation,  thought,  and  motion. 

This  disease  is  generally  observed  in  young  subjects  of  the  habit 
named  strumous.  So  far  as  I have  observed  or  read,  though  it 
takes  place  in  one  of  two  modes,  either  as  an  extension  of  the  ori- 
ginal disease  of  the  ear  and  cerebral  membranes,  or  an  alternating 
and  vicarious  result,  the  latter  is  most  frequently  its  genuine  cha- 
racter. The  abscess  is  contained  in  an  irregular  cavity,  surround- 
ed by  lymph  and  cerebral  matter,  which  is  very  vascular.  It  is  in 
all  cases  attended  with  inflammation,  thickening,  and  suppuration 
of  the  membranes.  The  pia  mater  is  highly  vascular,  and  more 
or  less  covered  with  lymph.  The  dura  viater  is  thick,  opaque, 
dark-coloured,  and  detached  from  the  bone. 

The  variety  of  abscess  now  mentioned  is  understood  to  depend 
upon  the  operation  of  internal  causes  only.  At  least  no  external 
cause  can  be  recognized ; and  if  it  were,  it  would  be  such  as  in 
other  subjects  would  perhaps  be  inadequate  to  the  effect.  There 


288 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


is,  however,  a class  of  purulent  collections  in  the  brain  which  in 
general  it  is  possible  to  trace  to  noechanical  violence  inflicted  on 
the  head ; and  it  is  remarkable  bow  long  a period  may  elapse  be- 
tween tbe  date  of  the  injury,  and  that  destruction  of  the  organ 
which  renders  the  continuance  of  life  impossible. 

Pigray  gives  a case  in  which  an  abscess,  the  size  of  a nut,  proved 
fatal  at  the  end  of  six  months  ;* * * §  and  Morand  mentions  one  in  which 
a soldier,  who  had  received  a shot  in  Italy,  after  slight  treatment 
of  the  wound,  proceeded  thence  to  Paris ; and  nine  months  elapsed 
before  suppuration  and  total  destruction  of  the  right  lobe  terminat- 
ed life.f 

In  a case  mentioned  by  Prochaska,  the  first  foundation  of  the 
disease  appears  to  have  been  frequent  beating  on  the  head  for  years, 
finally  carried  to  intensity  by  a blow  on  the  forehead,  five  months 
after  which  death  took  place.  | In  a case  by  Sir  E.  Home,  nearly 
nineteen  months  elapsed  between  tbe  receipt  of  tbe  injury  and  the 
fatal  termination. § In  one  by  Dr  Denmark,  the  interval  between 
the  supposed  injury  and  the  period  of  death  was  twelve  months.  || 
Many  similar  cases  are  found  in  the  writings  of  surgeons. IF  The 
result  is,  that  a portion  of  brain  more  or  less  extensive  is  convert- 
ed into  purulent  matter,  contained  in  general  in  a membranous 
cyst,  more  or  less  thick  and  vascular,  according  to  the  interval  be- 
tween tbe  infliction  of  the  injury  and  the  time  of  examination. 

Between  suppuration  of  the  brain,  from  internal  and  external 
causes,  a distinction  has  been  drawn  by  Baillie,  in  the  circum- 
stance, that  in  the  former  it  is  generally  in  the  substance,  and  in 
the  latter  on  the  surface  of  the  organ.  This  distinction  does  not 
hold  good  in  several  respects,  and  requires  modification.  Is^, 
Where  a long  interval  elapses  after  the  infliction  of  the  injury,  the 
collection  of  purulent  matter  is  almost  invariably  deep  seated.  2c?, 
In  like  manner,  when  the  injury  operates  in  the  manner  of  counter- 
stroke, the  collection  is  also  often  within  the  substance  of  the  or- 

* Libre  IV.  chap.  ix. 

t Opuscules  de  Chirurgie,  1.  c.  p.  159. 

$ Obs.  Patholog.  Section  iv.  apud  Opera  Minora,  p.  304. 

§ Transactions  of  a Society,  Vol.  III.  p.  94. 

II  Medico- Chirurgical  Transactions,  Vol.  V.  p.  24. 

H See  especially  several  cases  of  this  kind  in  the  writings  of  Loms,  Le  Dran,  Rava- 
ton  ; and  by  Volaire,  Journal  de  Med.  Vol.  XX.  p.  503.  Thilenius,  Med.  und  Chir. 
Bemerkungen.  Walther,  Obs.  33.  Thulstrup  Physicalks  BibUothek.  fiir  Danmark  1 
Band.  April.  Bailey  in  Med.  and  Phys.  Journal,  Vol.  XXIII.  p.  376. 


BRAIN. 


289 


gan.  (Pigray,  Quesnay,  Petit,  Chopart.*)  For  example,  several 
weeks  or  months  after  a blow  on  the  upper  or  fore  part  of  the  head, 
from  which  the  patient  never  perfectly  recovers,  but  is  more  or 
less  paralytic,  perhaps  occasionally  lethargic,  deaf,  blind,  or  fatu- 
ous, death  takes  place,  and  an  abscess  is  found  in  the  substance  of 
the  hemispheres,  in  the  corpus  striatum,  or  even  in  one  of  the  lobes 
of  the  cerebellum.  3c?,  In  some  instances  of  suppuration  after  in- 
jury, the  collection  does  not  take  place  at  the  part  at  which  the 
blow  struck  the  skull,  but  either  in  the  line  of  the  force  passing 
through  the  brain,  or  in  some  of  the  lines  into  which  this  force 
may  be  resolved.  4?7j,  It  is  chiefly  when  the  force  has  been  direct- 
ly expended  on  the  part,  i.  e.  when  the  hone  has  been  immediately 
broken,  and  its  membranes  injured,  that  suppuration  takes  place 
on  the  surface  of  the  brain.  This  suppuration  is  then  the  result 
rather  of  the  affection  of  the  membranes,  especially  of  the  pia 
mater,  than  of  the  cerebral  substance  itself.f 

Suppuration  may  take  place  in  any  part  of  the  brain  ; but  it  is 
most  frequent  in  the  hemispheres.  The  effects  which  it  produces 
vary  according  to  the  situation  and  the  extent  of  the  purulent  col- 
lection. They  are  much  the  same  as  from  the  presence  of  blood, 
tumours,  or  other  unusual  substances. 

In  the  circumstances  now  mentioned,  purulent  collections  are 
the  result  of  primary  inflammation,  spontaneous  or  traumatic.  I 
must  further  repeat  explicitly  what  has  been  already  said,  that  they 
take  place  in  a secondary  manner  in  fever.  Collections  of  purulent 
matter  within  the  brain  after  fever  were  first  distinctly  found  by 
Pringle,  afterwards  by  Borsieri  and  Eisfeld,|  and  more  recently 
by  Jackson  and  Mills.  These  are  doubtless  the  effects  of  inflam- 
mation, which,  however,  is,  in  this  case,  a secondary  and  adventitious 
circumstance  in  the  progress  of  the  disease. 

These,  nevertheless,  and  similar  phenomena,  have  been  conceived 
to  afford  evidence  that  fever  consists  in  inflammation  of  the  brain. 
It  is  unnecessary  to  examine  the  origin  of  this  theory ; the  first 
traces  of  which  may  be  found  in  the  writings  of  Willis,  Werlhof, 

* Memoire  sur  les  centre  coups  dans  les  lesions  de  la  tete.  Par  M.  Chopart.  Me- 
moires  pour  le  Prix.  de  la  Academie  Royale  de  Chirurgie,  Tom.  XI.  12mo. 

Traite  des  Plaies  de  Tete,  et  de  I’Encejshalite,  principalement  de  ceUe  qui  leur  est 
consecutive,  &c.  Par  J.  P.  Gama,  OfRcier  de  la  Legion  d’Honneur,  Chirurgien  en 
Chef,  &c.  Paris.  1830.  8vo. 

$ J.  F.  A.  Eisfeld  Meletemata,  Qufedam  ad  Historiam  Naturalem  Typhi  Acuti 
Lipsiae  aestivo  tempore,  anni  1799,  grassantes  pertinentia.  § xviii.  p.  72,  &c.  apud 
Brera,  Vol.  VI.  p.  1. 

T 


290 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Torti,  Donald  Monro,  and  a paper  of  M.  Marteau  de  Grand villiers.* 
Riel  appears  to  have  entertained  the  idea,  that  cerebral  inflamma- 
tion, though  not  the  cause  of  the  symptoms,  takes  place  in  fever. 
The  first  attempt,  however,  to  connect  the  phenomena  of  fever  with 
those  of  inflammation,  was  made  by  Ploucquet  of  Tubingen  in 
1800,t  and  this  was  more  expressly  undertaken  by  Costantin  of 
Leipzic  in  the  same  year,  in  consequence  of  an  epidemic  typhus 
which  had  prevailed  at  Leipzic  in  1799.  According  to  the  latter 
author.  Encephalitis^  by  which  he  understands  that  form  of  fever 
which  happens  to  the  cerebral  and  cerebellic  vessels  and  membranes, 
comprehends  three  genera,  Synocha,  Typhus,  and  Paralysis ; — the 
first  distinguished  by  increased  irritability,  with  normal  or  increas- 
ed reaction  ; the  second  by  increased  irritability,  but  impaired  reac- 
tion ; and  the  third  by  irritability  and  reaction  being  equally  im- 
paired, inert,  and  more  or  less  abolished. f 

These  ideas,  though  carried  to  an  extreme,  derive  some  support 
from  the  phenomena  of  fever,  and  the  morbid  changes  left  in  the 
brain.  They  were  afterwards  more  fully  developed  by  Clutterbuck  § 
and  Mills|  in  this  country,  and  by  MarcusIF  and  others  in  Germany. 

The  merits  of  this  theory  I have  already  attempted  partially  to 
appreciate.  Though  autoptic  examinations  prove  that  the  capilla- 
ries of  the  brain,  in  common  with  those  of  other  organs,  are  much 
overloaded  with  slowly  moving  blood,  this  state  differs  from  inflam- 
mation in  several  respects.  Suppuration,  especially,  is  not  a con- 
stant, or  is  rather  an  exceedingly  rare  occurrence,  and  is  to  be  re- 
garded as  adventitious,  or  depending  upon  accidental  peculiarities 
and  idiosyncrasies,  and  not  essential.  The  overloaded  state  of  the 
capillaries,  though  taking  place  in  those  of  the  organ  itself,  is  never- 
theless more  remarkable,  according  to  my  observation,  in  those  of 
the  proper  cerebral  membrane.  The  principal  character  of  that 
blood  is,  as  I have  above  shown,  that  it  is  non-arterialized,  and 
consequently  poisonous. 

* Description  des  Fievres  Malignes  avec  une  Inflammation  sourde  du  Cerveau,  &c. 
&c.  Par  AI  Marteau  de  Grandvilliers,  Medecin  de  I’Hopital  a Aumale,  Journal  de 
Medecine,  Tome  VIII.  1758.  p.  275. 

t G.  F.  Ploucquet  Expositio  Nosologica  Typhi.  Tubingen,  1800.  Tubing.  Anz. 
1800. 

J Caroli  Fred.  Costantin,  M.  D.  Dissertatio  de  Encephalitide.  Lips.  1800.  Ext.  in 
Brera  Sylloge,  Vol.  VI.  p.  72. 

§ An  Inquiry  into  the  Seat  and  Nature  of  Fever,  &c.  By  Henry  Clutterbuck,  M.D. 
&c.  Lond.  1807,  and  second  edition,  London,  1825. 

II  On  the  Utility  of  Blood-letting  in  Fever.  By  Thomas  Mills.  Dublin,  1819. 

11  Ephemeriden  der  Heilkunde.  Band  I.  Heft.  1. 


BRAIN. 


^291 


5.  Ulceration  I Erosion.  From  the  various  forms  of  pulpy  de- 
struction and  abscess,  the  transition  to  ulceration  is  easy.  By  this  is 
understood  destruction  of  part  of  either  of  the  surfaces  of  the  brain, 
so  as  to  present  a hollow  or  depressed  surface,  rough,  irregular,  and 
covered  partially  either  with  bloody  or  albuminous  exudation.  In 
the  former  case  its  claim  to  the  character  of  a genuine  ulcer  may 
be  doubtful,  since  it  may  be  view'ed  as  the  residue  of  a partial  effu- 
sion of  blood.  It  is  possible  that  this  may  have  been  the  origin  of 
the  case  of  erosion  of  the  corpus  striatum  described  by  IMorgagni, 
in  which  that  body  is  said  to  have  been  entirely  detached  from  the 
brain ; * and  I think  it  is  next  to  certain  this  was  the  cause  of  the 
ulcerous  cavity,  f which  he  shortly  after  states  was  found  in  the  base 
of  the  left  ventricle  of  another  case.  This  is  almost  admitted  by 
Morgagni  himself,  who  regards  these  ulcers  as  ruptured  cavities  or 
cells,  originally  formed  by  effused  serum.  (Ibid,  art  8.) 

So  far  as  accurate  observation  hitherto  goes,  the  genuine  ulcer 
is  found  chiefly  at  the  convoluted  surface  of  the  brain ; (Ridley,  p. 
212;  Powell,  case  6;)  or  the  foliated  surface  of  the  cerebellum 
(Haller,  Vol.  iv.  p.  351,)  and  is  always  connected  with  an  unsound 
state  of  the  proper  or  vascular  membrane.  Of  this  sort  of  ulcer, 
Stoll  found  an  instance  on  the  cerebellum  of  a young  man  of  twen- 
ty-six, accompanied  with  redness,  thickening,  and  erosion  of  the 
pia  mater.  | Two  cases  of  the  same  nature  are  recorded  by  Scou- 
tetten.  In  one,  the  lower  part  of  the  right  anterior  lobe  presented 
a hard,  dry,  irregular  surface,  thirteen  lines  long  and  seven  broad, 
with  irregular  indented  edges,  with  the  contiguous  cerebral  sub- 
stance sound.  In  the  other,  the  extremity  of  the  posterior  lobe  pre- 
sented two  small  ulcerated  patches,  one  oval,  six  lines  long,  and 
covered  with  deep  gray  pulpy  matter;  the  other  a linear  depres- 
sion,— both  with  wine-lee  colour  of  the  adjacent  brain.  In  both 
cases,  the  investing  proper  membrane  was  red,  injected,  and  some- 
what eroded.  § From  these  facts,  it  results  that  ulceration  of  the 
brain  is  an  effect  of  circumscribed  inflammation  of  the  pia  mater. 

The  instances  of  erosion,  or  ulceration  from  the  penetration  of 
foreign  bodies,  mentioned  by  Morgagni  and  various  surgical  authors, 
are  rather  examples  of  suppurative  destruction. 

6.  Encephalamia.  Hemorrhayia  Cerebri,  Hoffmann.  Hemor- 
rhage. Apoplexia  Sanguinea,  Sauvages,  Cullen,  &c.  Apoplexie  Ce- 

* Epist.  xi.  2.  -f  Ibid.  4. 

i Ratio  Medendi,  pars  tertia,  p.  1 22. 

§ Memoire  sur  quelques  cas  rares  d’Anatomie  Pathologique  du  Cerveau  &c.  Par 
Scoutetten,  D.  M.  P.  &c.  Archives  Generates,  Tome  VII.  31. 


292 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


rehrale  of  Serres.  One  of  the  great  uses  of  the  proper  or  vascular 
membrane  {pia  mater)  is  to  sustain  and  convey,  as  it  were,  the  minute 
arteries  into  the  substance  of  the  brain.  No  artery,  however  mi- 
nute, enters  this  organ  without  previously  passing  through  the  pia 
mater  ; and  if  the  carotid  and  vertebral  arteries  he  injected,  the  ce- 
rebral matter  may  be  washed  away  entirely ; while  all  the  vessels, 
by  which  it  was  traversed,  are  seen  issuing  from  the  attached  surface 
and  numerous  processes  of  this  membrane.  The  vessels  thus  de- 
monstrated consist  of  minute  arteries  and  veins,  through  which,  in 
the  sound  or  normal  state,  the  blood  moves  uniformly  and  easily 
without  undergoing  any  permanent  retardation.  Dissection,  how- 
ever, shows,  that  from  various  causes,  either  the  whole  of  these  ves- 
sels, or  a certain  cluster  or  set  of  them,  may  become  inordinately 
distended  with  blood ; while  others,  which,  in  consequence  of  con- 
veying colourless  fluid  previously,  eluded  observation,  now  becom- 
ing injected  with  red  blood,  are  rendered  visible.  The  existence 
of  this  state  is  proved  by  cutting  into  thin  slices  the  brains  of  per- 
sons cut  off  in  this  condition,  when  numerous  blood-drops  follow 
each  incision,  and  each  part  is  penetrated  by  a much  greater  number 
of  vessels  than  natural.*  The  exquisite  or  most  perfect  degree  of 
this  state  is  when  the  blood-drops  enlarge  immediately  after  inci- 
sion,— a circumstance  from  which  a very  inordinate  quantity  of  fluid 
blood  in  the  cerebral  vessels  is  indicated,  f 

This  state  of  the  cerebral  vessels  is  similar  to  that  of  inflamma- 
tion. The  patient  is  highly  sensible  to  transitions  of  heat  and  cold ; 
the  skin  is  hot  and  dry ; the  tongue  foul ; the  stomach  disordered, 
and  the  urine  high-coloured  and  sedimentous.  The  pulse  is  full 
and  strong,  sometimes  hard,  but  not  frequent.  The  local  complaints 
are  dull  pain  and  weight  of  the  head,  occasional  giddiness,  indis- 
tinctness of  vision,  or  dazzling  of  the  eyes,  and  more  or  less  aboli- 
tion of  memory.  When  blood  is  drawn,  I have  found  it  present  a 
thick,  tough,  huffy  coat ; an  observation  in  which  I And  I am  anti- 
cipated by  Stoll  j;  and  Sir  Gilbert  Blane. 

When  the  above  phenomena  have  continued  for  a few  hours, 
sometimes  a day  or  two,  according  to  circumstances,  the  individual 
falls  down  destitute  of  sense  and  motion,  and  continues  so  for  a 
short  time.  After  a little,  recollection  gradually  returns,  and  with 
it  sensation  and  the  power  of  moving  the  limbs,  though  not  with 
such  freedom  as  before.  A sense  of  tingling  and  numbness  may 

* Morgagni  passim,  especially  iii.  and  iv. 

■f  Morgagni  epist.  x.  17  and  18. 

$ Ratio  Med.  Pars  v.  p.  31.  Vienna,  1789. 


BRAIN. 


293 


remain  in  an  arm  or  leg  for  some  time.  This  is  the  simplest  and 
mildest  form  of  the  apoplectic  seizure.  {Cataphora.) 

It  has  been  thought  that  this  could  not  happen  unless  blood  is  ef- 
fused ; but  various  instances  have  occurred  to  competent  observers 
in  which  the  cerebral  vessels  are  loaded  only,  and  in  which  effusion 
had  not  yet  taken  place.  It  may  further  be  inferred,  that  the  in- 
stances in  which  persons  recover  from  complete  apoplectic  seizure 
without  suffering  palsy  depend  upon  vascular  injection  only.  That 
fatal  cases  even  may  result  from  mere  accumulation,  is  admitted 
by  Morgagni,*  afterwards  by  Baillie,f  without  being  aware  that  the 
observation  had  been  made,  and  by  Rochoux,  who  thinks,  however, 
that  it  is  notuniform.J  I observe,  nevertheless,  that  M.  Rochoux 
forgets  that  the  cases  in  which  it  occurs  being  less  frequently  fatal, 
are  more  rarely  the  subject  of  inspection. 

According  to  M.  Serres,  indeed,  cases  of  apoplectic  seizure 
without  palsy  depend  on  injection  of  the  membranes  exclusively. § 
This  point  shall  be  afterwards  considered  when  speaking  of  the 
cerebral  membranes.  In  other  respects,  however,  the  researches  of 
this  physician  tend  to  establish  the  general  inference,  that  extrava- 
sation is  not  necessary  to  apoplexy.  \st.  From  experiments  made 
on  living  animals,!  from  the  phenomena  of  effusions  of  blood  either 
spontaneously,  or  from  wounds  and  injuries  of  the  head,  it  appears 
that  a considerable  quantity  of  blood  or  other  fluid  may  be  effused 
in  various  parts  of  the  brain  without  causing  apoplectic  symptoms. 
(Wepfer,  Valsalva,  and  Serres).  2c?,  From  various  cases  it  ap- 
pears that  the  apoplectic  symptoms  connected  with  extravasation 
disappear,  while  the  extra vasa ted  blood  remains.  (Serres’s  cases, 
7,  8,  7,  10,  11,  12,  and  others.)  3<?,  It  results  from  cases  record- 
ed not  only  by  Morgagni,  Baillie,  and  Rochoux,  as  above  mention- 
ed, but  by  the  physicians  of  Breslau,1[  by  Quarin,  by  Stark,**  and 

* Epist.  iii.  25  and  26. 

+ “ The  milder  forms  of  apoplexy  depend  upon  a distension  of  some  of  the  vessels 
of  the  brain  from  undue  accumulation  of  blood  in  them.  I have  known,  however,  one 
instance  of  fatal  apoplexy,  where  many  of  the  blood-vessels  were  found,  upon  exami- 
nation after  death,  to  be  much  distended  with  blood  ; but  no  blood  had  been  extrava- 
sated  in  any  part  of  the  brain.” — Lectures  and  Observations  on  Medicine.  London, 
1825,  p.  167. 

J Recherches  sur  TApoplexie.  Par  J.  A.  Rochoux.  Paris,  1814. 

§ Nouvelle  Division  des  Apoplexies  ; par  M.  Serres  ; Chevalier,  &c.  Annuaire 
Medico-Chirurgicale  des  Hopitaux  et  Hospices  Civiles  de  Paris.  A Paris,  1817.  4to, 
p.  246,  277. 

II  Annuaire  Medico-Chirurgicale,  260,  261. 

11  Historia  Morborum  Vratislaviensium. 

**  Clinical  and  Anatomical  Observations,  Part  iv.  § 4,  p.  73.  This  appears,  how- 


294 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


more  recently,  I may  add,  by  Dr  Abercrombie,  that  complete 
symptoms  of  apoplexy  may  result  from  mere  general  injection  of 
the  cerebral  vessels.  The  satne  phenomenon  appears  to  have  been 
witnessed  by  Cheselden.  (Book  iii.  chap.  14,  p.  224.)  If,  on  this 
point,  my  own  observation  be  entitled  to  any  weight,  I may  add, 
that  in  1817  I had  occasion  to  examine  the  body  of  a young  wo- 
man who  died  with  all  the  symptoms  of  well-marked  apoplexy ; and 
though  every  part  of  the  brain  was  cut  into  minute  portions  with 
the  iitraost  care,  no  effusion  of  red  blood  could  be  recognized.  The 
only  abnormal  appearance  was  some  injection  of  the  vessels  going 
to  the  annular  protuberance  and  medulla  oblongata.*  Though 

in  several  cases  of  persons  cut  off  with  well-marked  apoplectic 
symptoms,  I have  found  extravasated  blood,  it  bore  no  proportion 
to  the  severity  of  the  disease.  Instead  of  being  in  the  shape  of 
clots  in  distinct  cavities,  it  consisted  simply  of  long  linear  streaks 
of  blood  stretching  through  parts  of  the  brain,  sometimes  in  the 
neighbourhood  of  blood-vessels.  In  sucb  cases,  however,  the  blood- 
vessels were  much  injected,  especially  in  the  vicinity  of  the  mem- 
branes. In  other  instances  capillary  injection  is  observed  in  the 
corpora  striata  or  substance  of  the  hemispheres.  This  is  the  capil- 
lary apoplexy  of  M.  Cruveilhier. 

Upon  the  whole,  I conceive  it  legitimate  to  infer,  that  the  essen- 
tial anatomical  character  of  apoplexy  is  injection  of  the  vessels  of 
the  brain  more  or  less  general.  This  may  terminate  in  one  of  two 
modes,  both  of  which  are  accidental  and  accessory.  The  first  is  ef- 
fusion of  serous  fluid  ; the  second  is  effusion  of  red  blood. 

Serous  fluid  exhaled  from  the  capillaries  has  been  supposed  to 
constitute  a peculiar  form  of  apoplexy  entirely  distinct  from  that 
termed  sanguine,  and  depending  on  extravasation  of  blood.  In. the 
writings  of  raorgagni  and  others  are  cases  in  which  the  effusion  of 
serous  fluid  was  associated  with  distinct  and  general-  vascular  injec- 
tion. Cases  of  this  description  are  referred  by  Stoll  to  the  head  of 
sanguine  apoplexy,  in  which  the  pathological  character  is  injection 
or  accumulation,  which  is  at  once  the  cause  of  the  serous  effusion 
and  of  the  apoplectic  symptoras.f  It  was  afterwards  demonstrated 

ever,  to  have  been  a case  depending  on  vascular  injection  of  the  medulla  oblongata  axii 
spinal  chord. 

* Case  of  Ann  Dinwiddle.  Clinical  Ward. 

-|-  “ In  apoplecticorum  secto  cerebro  frequenter  leguntur  vasa  cerebri  sanguine  tur- 
gida,  et  serum  multum  effusum.  Hujus  generis  apoplexi®  plerumque  serosm  audiunt. 
Verius  sanguinece  appellarentur  ; accumulatus  enim  intra  caput  sanguis,  et  seri  effusi, 
et  apoplexia;  causa  est ; serum  ipsum  effrisum  ad  concatisas  pevtinet  scrim  accedentes. 


BRAIN. 


295 


by  Portal,  that  serous  infiltration  and  eflFusion  invariably  arise  from 
the  same  state  of  the  vessels  as  hemorrhage;*  and  this  inference 
has  since  been  confirmed  by  the  observations  of  Dr  Cheyne,  Dr 
Abercrombie,  of  M.  Serres,  and  others.  In  short,  if  from  any 
cause  the  circulation  within  the  head  becomes  unusually  slow,  and 
the  vessels  of  the  brain  become  inordinately  distended,  either  red 
blood  or  serous  fluid  is  poured  out  from  the  extremities  of  the  ar- 
teries. The  latter  process,  if  we  admit  the  testimony  of  Chesel- 
den,|  Morgagni,!  and  Willan,§  takes  place  in  the  slow  and  gra- 
dual drowsiness  and  stupefaction  which  distinguish  the  form  of  the 
disease  termed  lethargy  ; {veterniis.y^  The  cause  of  the  symptoms, 
however,  is  not  the  effusion,  as  Willan  imagined,  but  the  general 
vascular  distension  and  injection  from  which  the  effusion  arises. 

Hemorrhage,  nevertheless,  takes  place  in  a considerable  propor- 
tion of  cases.  Howship  says  in  nine  of  ten ; but  this  is  evidently  a 
general  assertion  founded  on  no  accurate  elements.  From  the  dis- 
tended vessels  blood  escapes,  though  whether  by  exhalation  or  by 
actual  rupture  is  not  agreed ; and,  forcing  its  way  through  the 
cerebral  substance,  breaks  it  down,  and  forms  a sort  of  hollow  or 
cavern,  in  which  it  coagulates.  If  the  quantity  be  considerable  ; 
if  it  be  effused  suddenly,  and  in  certain  parts  of  the  brain  ; (optic 
thalamus,  annular  protuberance,  brain-limbs,  and  medulla  oblon- 
gata ,-)  if  the  cerebral  injection  continues,  notwithstanding  the  dis- 
charge and  the  use  of  remedies,  complete  coma  very  soon  termi- 
nates in  death ; and  on  dissection  more  or  less  blood  is  found  in 
some  part  of  the  substance  of  the  brain,  and  the  vessels  are  much, 
sometimes  exceedingly  injected  with  fluid  blood. 

When  the  effusion  is  not  copious,  or  dependent  upon  very  ge- 
neral injection  of  the  cerebral  vessels,  nor  take  place  suddenly,  or 
in  a vital  part  of  the  brain ; or  if  the  injection  is  thereby,  or  bv 
other  means  moderated ; then  further  changes^ take  place,  and  con- 
tinue until  the  natural  structure  of  the  organ  is  so  much  altered 
that  life  can  no  longer  be  continued.  The  effused  blood,  both 

qumve  morbiim,  ipmm  non  produxere,  attamen  productum  augcnV'  Rationis  Medendi, 
Pars  i.  p.  138.  Lugduni  Bat.  1780. 

* Sur  la  Nature  et  le  Traitement  de  Plusieurs  Maladies,  &c.  Tome  I.  p.  280  ; et 
Sur  I’Apoplexie,  et  Sur  les  Moyens  de  la  prevenir.  Paris,  1811.  Tome  II.  p.  216. 

•]-  The  Anatomy  of  the  Human  Body.  Book  iii.  chap.  14. 

J Epist.  vi. 

§ Reports  on  the  Diseases  in  London.  By  Robert  Willan,  M.  D.  &c.  1799,  p.  338, 
8vo  edit.  1821. 

11  Thom«  Willis,  De  Anima  Brutorum,  Pars  Pathol.  Cap.  14. 


296 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


when  fluid,  and  especially  after  coagulation,  acts  as  a foreign  body, 
— breaks  down,  softens,  and  disorganizes  the  part  with  which  it  is 
in  contact.  After  some  time  the  clot  begins  to  change,  assumes  a 
brown  or  brownish-black  colour,  and  is  separated  into  fragments 
floating  in  a wine-lee  fluid.  The  further  dissolution  of  these  forms 
a homogeneous  chocolate -coloured  matter,  which  is  eventually  re- 
moved more  or  less  perfectly  ;*  while  the  part,  which  the  extrava- 
sation converted  into  a hollow,  is  filled  with  serous  fluid,  and  sof- 
tened or  pulpy  cerebral  matter.  In  some  cases  of  complete  re- 
covery this  is  gradually  converted,  by  a slow  process  of  adhesive 
inflammation,  into  a membranous  substance,  harder  than  the  sur- 
rounding brain,  which,  however,  is  generally  softer  than  sound  ce- 
rebral matter.  (Lerminier,  cases  1,  2.)  In  this  manner  are  formed 
the  cavernous  sacs  described  by  Wepferand  Morgagni,  (Epist.  hi. 
7,  8,  9,  lx.  2,  6,)  and  the  cavities  described  by  Baillie,  (450,  455,) 
Wilson,  Abernethy,t  and  others. 

The  contiguous  enclosing  cerebral  matter  also  undergoes  pecu- 
liar changes,  which  vary  with  the  interval  between  extravasation 
and  death.  The  portion  in  immediate  contact  with  the  clot  is  ge- 
nerally dark  red,  wine-lee  colour,  or,  at  later  periods,  of  a choco- 
late brown,  and  rather  pulpy.  The  portion  exterior  to  this  is 
paler,  and  of  an  orange  colour,  but  generally  much  penetrated  by 
distended  vessels.  Exterior  to  this  again  may  be  in  general  dis- 
tinguished a layer  of  bluish-white  or  bluish-yellow  matter,  gradu- 
ally terminating  in  sound  brain,  but  all  more  or  less  traversed  by 
blood-vessels.  In  other  cases,  in  which  a longer  period  elapses 
between  extravasation  and  death,  the  portion  of  brain  enclosing  the 
clot  is  pulpy,  of  a dun-red  or  orange-colour,  passing  to  yellow,  and 
terminating  gradually  in  brain  of  natural  colour  and  consistence. 
In  both  cases  minute  shreds  of  cerebral  matter  and  filamentous 
threads  may  he  traced  in  the  pulpy  matter  and  in  the  bloody  clot, 
either  recent  or  dissolved  into  the  chocolate-coloured  fluid.  By 
some  these  filamentous  threads  are  supposed  to  be  the  fine  cellular 
tissue  of  the  brain  ; but  I think  it  impossible  to  doubt  that  they  are 

* “ The  appearance  of  the  effused  blood  differs  according  to  the  duration  of  its  ef- 
fusion. Wlien  death  ensues  quickly,  at  the  end  of  three  or  four  days,  for  example,  it 
is  in  the  form  of  soft  blackish  clots.  After  a month  or  six  weeks  it  becomes  firmer, 
assumes  a deep  brown  colour,  and  resembles  the  blood  of  aneurismal  tumo'ii's.  At  a 
more  remote  period  it  becomes  still  more  compact  and  of  a pale  red  colour,  bordering 
on  ochreous  yellow.  Lastly,  it  is  entirely  absorbed.” — Rochoux,  p.  86. 

Surgical  Works,  Vol.  II.  On  Injuries  of  the  Head,  pp.  18,  19,  and  20.  London, 

1811. 


BRAIN. 


297 


minute  capillary  vessels.  This  general  description  I have  derived 
partly  from  the  description  of  Rochoux,*  but  especially  from  those 
ofLerminier  and  Serres,f  and  partly  from  personal  observation. 

The  change  in  the  structnre  and  consistence  of  the  brain  sur- 
rounding the  clot  forms  one  variety  of  softening  {I'amollissement,') 
or  pulpy  disorganization ; and  notwithstanding  the  opinion  expressed 
by  Pariset,  Recamier,  Rochoux, J and  others,  that  it  is  the  cause  of 
the  effusion,  it  is  invariably  the  effect  either  of  this  or  of  the  preli- 
minary injection.  This  is  established  not  only  by  the  facts  already 
mentioned,  but  by  the  cases  of  Morgagni,  of  M.  Dan  de  la  V au- 
terie,§  and  especially  by  those  ofLerminier  and  Serres.|| 

Vascular  injection,  with  or  without  bloody  effusion,  may  take 
place  in  any  part  of  the  brain ; but  certain  parts  are  much  more 
commonly  the  seat  of  this  discharge  than  others.  Thus  Morgagni, 
treading  in  the  steps  of  Bonetus,  justly  remarked,  that  either  bloody 
effusion,  or  the  caverns  formed  by  it,  are  found  almost  always  in 
the  striated  bodies,  or  in  the  optic  thalami^  or  in  both,  while  the 
anterior  part  of  the  hemisphere  was  very  rarely,  and  the  posterior 
part  almost  never  affected.lf  The  general  accuracy  of  this  conclu- 
sion is  in  some  degree  confirmed  by  modern  observation,  which,  in 
a majority  of  cases,  has  found  the  striated  and  optic  bodies  diseased. 
Rochoux  particularly  shows,  that  of  forty-one  cases  of  bloody  effu- 
sion terminating  fatally,  twenty-four  were  found  in  the  corpus  stria- 
tum, two  in  the  optic  thalamus,  one  in  the  corpus  striatum  and  optic 
thalamus,  and  one  beneath  the  corpus  striatum;  while  only  thirteen, 
not  more  than  one-half,  were  found  in  other  parts  of  the  brain. 
The  reason  of  this  is  to  be  found  in  the  anatomical  relations  of  this 
part  of  the  brain.  Near  the  beginning  of  the  fissure  of  Sylvius  is 
situate  the  white  perforated  spot  of  Vicq-d’Azyr  (“substance  blanche 
que  j’appelle  perforee”)  Through  these  orifices  the  Sylvian  or 
middle  artery  of  the  brain,  w'hich  lies  in  the  fissure,  transmits  a 
great  number  of  arteries  of  various  sizes  into  the  substance  of  the 
brain,  and  through  the  cerebral  nucleus  {corpus  striatum,')  which 
lies  immediately  over  this  perforated  spot.  This  arrangement  ren- 
ders the  striated  body,  or  rather  the  striated  nucleus,  the  most 
vascular  part  of  the  whole  organ,  and  the  most  liable,  when  the 
cerebral  vascular  system  is  overloaded,  to  effusion  of  blood. 

* Recherches.  Cases,  passim.  Article  pp.  87,  88.  Section  ii.  art.  2. 

t Annuaire  JMedico-Chirurgicale.  Lerminier,  Cases  4,  .5,  7,  8.  Serres,  various  cases 
in  § 12.  Apoplexie  Cerehrale. 

i Recherches,  &c.  pp.  88  and  89.  § These  soutenue,  &c. 

II  Annuaire,  loco  citato.  ^ Epistola  iii.  18. 


298 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


This  doctrine  is  not,  however,  altogether  free  from  objection. 
By  M.  Serres  especially  it  has  been  said  that  hemorrhagic  cavities 
are  formed  in  the  fore  part,  the  middle,  or  the  posterior  part,  of  the 
hemispheres,  without  affecting  the  thalami  or  striated  bodies,  much 
more  frequently  than  is  represented  by  Bonetus,  Morgagni,  and 
Rochoux.  I find  from  examining  the  cases  of  Howship,  Lerminier, 
Serres,  Tacheron,  and  others,  that  this  is  not  entirely  without  foun- 
dation. Of  6 cases  of  cerebral  hemorrhage  given  by  Lerminier, 
3 are  in  the  hemispheres,  1 in  the  right  optic  thalamus,  one  in  the 
left  optic  thalamus,  and  1 in  the  left  corpus  striatum*  Of  7 cases 
of  cerebral  hemorrhage  given  by  Serres,  two  are  in  the  centre  or 
posterior  part  of  the  left  hemisphere,  1 in  both  hemispheres,  1 in 
the  left  hemisphere  and  in  the  mesolobe,  and  3 in  the  annular  pro- 
tuberance.! Among  19  cases  of  cerebral  hemorrhage  or  its  effects, 
recorded  by  Tacheron,  5 were  in  the  right  hemisphere,  and  4 in 
the  left,  2 were  in  the  posterior  part  of  the  right  hemisphere,  2 in 
the  substance  of  the  optic  eminences,  2 in  that  of  the  striated  bo- 
dies, 1 in  the  mesolobe  and  adjoining  part  of  the  left  ventricle,  I in 
the  annular  protuberance,  1 in  the  optic  eminence  and  striated  body 
at  once ; and  in  one,  in  which  the  last  extravasation  took  place  in 
the  right  optic  thalamus,  one  cyst  was  found  in  the  neighbourhood 
of  the  cylindroid  eminence,  another  in  the  centre  of  the  left  optic 
thalamus,  and  a third  in  the  annular  protuberance.! 

Upon  the  whole,  we  are  in  possession  of  few  very  accurate  ele- 
ments to  determine  this  question.  From  the  authentic  cases,  how- 
ever, which  I have  perused,  for  it  is  in  vain  to  di’aw  conclusions 
from  individual  observation  only,  I think  there  are  grounds  to  infer, 
that,  next  to  the  striated  nucleus,  the  hemispheres  are  the  most 
frequent  seat  of  cerebral  injection  and  hemorrhage.  It  is  worthy 
of  remark,  that  the  extravasation,  when  it  takes  place,  does  so 
chiefly  on  the  outer  side  of  the  lateral  ventricle,  generally  towards 
its  posterior  end,  and  in  that  portion  of  brain  which  forms  the  ex- 
ternal-lateral boundary  of  the  optic  thalamus,  separated  from  the 
ventricle  by  a thin  plate.  Into  the  ventricle  it  rarely  takes  place 
primarily ; and  when  blood  is  found  there,  it  is  the  result  either  of 
bloody  extravasation  in  the  hemisphere  breaking  down  the  floor,§ 

■*  Annuaire  Medico-Chimrgicale,  p.  213,  et  ensuite. 

t Ibid.  p.  324,  §.  xi.  et  ensuite. 

^ Recherches  Anatomico-Pathologiques,  &c.  par  C.  F.  Tacheron,  Doct.  a Medecine, 
&c.  Tome  Illme.  Paris,  1823.  Ordre  4trieme,  2ieme  genre.  Case  31st. 

§ Howship,  Case  15,  19. 


BRAIN. 


299 


the  wall,  or  the  ceiling  of  the  ventricle,  or,  as  shall  be  afterwards 
shown,  it  issues  from  the  choroid  plexus.  The  same  remark  applies 
to  blood  on  the  surface  of  the  brain. 

In  this  process  the  hemorrhage  produces  extensive  laceration  of 
the  substance  of  the  hemisphere  attacked  ; and  if  the  hlood  effused 
be  copious,  and  the  laceration  of  the  hemisphere  great,  the  lesion 
proves  speedily  fatal.  This  fact  I have  verified  by  several  cases 
carefully  observed  and  examined  after  death ; and,  in  order  to  il- 
lustrate more  clearly  the  nature  of  the  lesion  and  its  attendant 
effects,  I shall  mention  shortly  the  condition  of  the  brain  in  one 
extreme  case.  A quantity  of  dark-coloured  blood,  spread  over  the 
surface  of  the  brain,  was  found  on  the  anterior,  superior,  and  lateral 
regions  of  the  right  hemisphere.  This  was  thin  at  the  posterior  and 
superior  part  of  the  hemisphere,  that  is,  about  the  thickness  of  a 
half-crown  piece,  diminishing  to  that  of  a shilling.  At  the  anterior 
lohes  it  became  much  thicker,  and  at  their  lower  surface  and  the 
anterior  end  of  the  mesolobe  {corpus  callosum),  it  was  at  least  one- 
fourth  of  an  inch  thick.  It  was  spread,  much  to  the  same  extent 
and  of  the  same  dimensions,  over  the  olfactory  nerves  and  inferior 
surface  of  the  anterior  lohes,  over  the  optic  chiasma,  pisiform  emi- 
nences, and  most  of  the  whole  lower  surface  of  the  middle  lobe.  A 
lacerated  opening  had  taken  place  at  the  inner  margin  of  the  right 
hemisphere  where  it  is  joined  to  the  mesolobe,  and  by  this,  which 
had  forcibly  torn  up  the  mesolobe  from  its  connections  with  the 
hemisphere,  the  blood  had  escaped,  and  gradually  spread  itself  over 
the  lower,  anterior,  and  superior  surfaces  of  the  hemisphere. 

It  was  then  found  that  a large  lacerated  cavity  had  been  formed 
in  the  substance  of  the  right  hemisphere,  about  three  inches  long, 
tapering  at  each  end,  but  about  two  inches  or  one  inch  and  a half  in 
diameter  at  middle  ; that  from  this  the  blood  had  escaped  by  one  la- 
cerated opening  anteriorly  to  the  surface  of  the  brain ; and  by  a 
lateral  one  into  the  ventricle,  which  was  also  filled  with  blood. 

Cases  of  the  kind  now  specified  are  of  extreme  violence,  and  not 
only  fatal,  but  very  speedily  fatal.  It  has  been  said  that  apoplexy, 
that  is,  cerebral  hemorrhage,  is  not  a speedily  fatal  disease  ; and, 
under  certain  restrictions,  this  is  correct.  It  is  indeed  not  instanta- 
neously fatal,  like  the  bursting  of  an  aortic  aneurism,  or  the  sudden 
death  following  on  disease  of  the  valves  of  the  aorta  or  the  heart. 
According  to  Rochoux,  the  shortest  time  that,  in  the  most  rapid 
cases,  elapses  between  the  first  appearance  of  the  symptoms  and  the 


300 


GENEEAL  AND  PATHOLOGICAL  ANATOMY. 


occurrence  of  the  fatal  termination,  is  sixteen  hours.  I am  satisfied, 
nevertheless,  from  several  facts,  as  well  authenticated  as  these  can, 
under  the  circumstances,  be,  that,  in  the  cases  now  adverted  to, 
the  interval  between  the  first  attack  and  the  cessation  of  life  is 
much  shorter.  In  one  case,  in  which  my  attention  was  particu- 
larly directed  to  this  point,  the  interval  between  the  first  symptoms 
and  the  extinction  of  life  might  be  six  hours,  but  did  not  exceed 
eight  hours.  In  other  cases  there  is  good  reason  to  believe  that 
the  interval  was  not  more  than  five  hours. 

The  cause  of  this  speedy  extinction  of  life,  compared  with  other 
cases,  is  to  be  found  in  two  circumstances ; the  large  quantity 
of  blood  effused,  and  consequently  compressing  a large  extent  of 
the  brain  and  suspending  its  functions ; and,  2ff,  the  great  injury 
inflicted  on  the  brain  by  laceration  of  its  substance,  disorganization 
of  its  structure,  and  consequent  disorder  and  suspension  of  its  func- 
tions. The  amount  of  effused  blood,  in  short,  and  the  great  extent 
of  brain  injured,  place  this  lesion  as  to  fatality  and  speedy  influence 
on  the  same  footing  with  effusion  of  blood  into  the  substance  of  the 
annular  protuberance. 

Next  to  the  hemispheres  in  hemorrhagic  tendency  may  be  placed 
the  protuberance,  the  limbs  of  the  brain,  the  medulla  oblongata,  and 
the  cerebellum,  in  the  order  now  enumerated. 

When  hemorrhage  takes  place  into  the  annular  protuberance, 
the  blood  is  generally  deposited  in  layers  in  the  interstices  between 
the  transverse  fibres.  In  one  fatal  case  I observed  this  so  distinctly, 
that  the  blood  and  cerebral  matter  formed  alternating  layers. 
When  it  is  very  abundant,  however,  the  transverse  fibres  are  broken 
through,  and  the  effused  blood  is  contained  in  irregular  cavities. 
(Cheyne,  case  9,  Serres,  Tacheron.)  The  proximity  of  the  protu- 
berance to  the  large  transverse  branches  of  the  basilar  artery  affords 
some  reason  for  the  readiness  with  which  it  may  be  affected  with 
vascular  injection  and  hemorrhage. 

Of  effusion  into  the  cerebellum  little  is  accurately  known.  Mor- 
gagni records  two  cases,  one  in  both  hemispheres,  most  in  the  left ; 
and  it  is  interesting  to  remark,  that  he  lays  particular  stress  on  the 
pulpy  state  of  the  surrounding  substance  of  the  cerebellic  hemi- 
sphere.* In  the  other,  it  appears  to  have  been  more  recent.  In 
a case  by  Dr  Abercrombie  a clot  was  found  in  the  right  hemisphere. 

■*  “ Ea  autem  portio  cerebelli  quse  corpus  ejusmodi  circumstabat,  fradda  erat.” 
Epistola  ii.  22.  Epist.  lx.  6. 


BRAIN. 


301 


Howship  furnishes  a curious  case  of  extravasation  into  the  medulla 
oblongata^  in  which  parallel  layers  of  blood  were  deposited  trans- 
versely in  the  substance  of  the  part.*  (Case  20.) 

Genuine  hemorrhage  of  the  brain,  as  now  described,  though  is- 
suing from  the  capillaries,  is  thought  not  to  take  place  by  exhala- 
tion.! It  is  never  possible  to  trace  it  to  a single  vessel ; and  he- 
morrhage from  rupture  of  an  arterial  trunk,  though  producing  the 
same  symptoms,  belongs  anatomically  to  a different  head.  Cheyne,| 
and  more  recently  Lerminier  and  Serres,  appear  to  have  found  al- 
ways many  minute  capillaries  opening  into  the  hemorrhagic  cavity. 

On  the  greater  frequency  of  affection  of  the  right  side  of  the 
brain  nothing  very  satisfactory  has  been  ascertained.  Morgagni 
believing  it,  ascribes  it  to  the  greater  frequency  with  which  the 
muscles  of  the  right  side  are  used  than  those  of  the  left.  In  41 
cases,  however,  given  by  Rochoiix,  the  number  in  the  left  was  18, 
that  in  the  right  17,  and  that  in  both  sides  6,  which  proves  that 
this  cannot  be  established  with  any  precision. 

It  is  important  to  ascertain  the  influence  which  bloody  effusion 
in  different  parts  of  the  brain,  exerts  on  the  functions  of  sensation, 
voluntary  motion,  and  the  muscles  of  respiration.  For  there  is 
reason  to  believe,  that,  according  as  congestion  or  hemorrhage  takes 
place  in  the  hemispheres,  in  the  striated  bodies,  in  the  annular  pro- 
tuberance, in  the  cerebellum,  or  in  the  medulla  oblongata,  the  effects 
produced  will  be  palsy,  or  apoplexy  more  or  less  violent,  and  with 
different  degrees  of  lethargic  or  comatose  affection.  The  inquiry 
is  beset  by  this  difficulty,  that  not  the  extravasation,  hut  the  injec- 
tion, is  the  essential  cause  of  death.  Scarcely  a part  of  the  brain 
has  been  found  unaffected  in  fatal  cases.  Itis  certain  thateffusion  into 
the  white  matter  of  the  hemispheres,  and  into  the  striated  nucleus,  is 
not  essentially  and  invariably  fatal,  unless  from  the  size  of  the  rent 
in  the  brain  and  the  amount  of  blood  effused.  For  from  cases  of 
this  kind  temporary  recovery  has  taken  place.  Neither  is  the  in- 
ference of  Bichat,  that  effusion  into  the  protuberance  is  invariably 
fatal,  well-founded.  Tacheron  records  a case  in  which  temporary 
recovery  was  effected.  It  must  be  admitted,  nevertheless,  that  ef- 
fusion into  this  part  is  more  likely  to  be  fatal  than  into  any  other. 
The  cases  of  Serres  afford  the  explanation  of  this  fact,  by  showing, 
that  injury  done  to  the  protuberance  causes  a severe  and  permanent 

* Practical  Observations  on  Surgery  and  Morbid  Anatomy,  &c.  By  John  Howship. 
London,  1816. 

+ Bichat,  Anatomie  Generale,  Tome  II.  article  iii.  p.  279. 

X Cases  of  Apoplexy  and  Lethargy.  8vo,  London,  1812. 


302 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


lesion  of  the  function  of  the  lungs,  the  vessels  of  which  become  dis- 
tended with  unrespired  blood,  while  the  air-vesicles  are  ruptured, 
and  death  is  effected  by  asphyxia. 

The  state  of  the  cerebral  vessels  which  terminates  in  hemorrhage 
may  occur,  perhaps,  at  any  period  of  adult  life.  But  these  blood- 
vessels are  liable  to  a peculiar  state  which  predisposes  to  impeded 
motion,  accumulation,  and  extravasation.  This  consists  in  deposi- 
tion of  earthy  matter  between  the  coats  of  the  internal  carotid  arte- 
ries, and  of  the  basilar  artery  and  their  branches.  In  consequence 
of  this  deposition,  they  lose  much  of  their  contractile  and  distensile 
powers,  and  some  of  their  tenacity ; become  rigid,  brittle,  and  less 
able  to  perform  their  functions  as  transmissile  tubes ; and  whenever 
blood  is  accumulated  in  unusual  quantity,  as  they  do  not  so  readily 
admit  of  distension,  rupture  is  the  consequence.  (Baillie,  454.) 
Hodgson  also  shows  how  generally  this  my)rbid  state  of  the  cere- 
bral arteries  is  connected  with  extravasation,* 

This  cause,  however,  is  predisponent  only.  A fit  of  apoplexy 
may  occur  and  prove  fatal  in  persons  in  whom  neither  ossification 
of  the  arteries  of  the  brain,  nor  any  other  state,  except  mere  vascu- 
lar injection,  is  found.  And,  on  the  other  hand,  the  cerebral  ar- 
teries may  be  ossified  or  steatoraatous,  in  many  persons  who  have 
never  had  a single  fit  of  apoplexy.  The  general  result  of  the  cases 
observed  by  Vater,  Morgagni,  Cheyne,  Howship,  Rochoux,  Serres, 
and  Tacheron,  is,  that  disease  of  the  arterial  coats  is  connected  with 
vascular  injection,  which  may  terminate,  according  to  circumstances, 
in  serous  effusion,  pulpy  destruction,  or  bloody  extravasation.  It 
is  a well  established  fact,  however,  that  the  extravasation  does  not 
take  place  from  the  diseased  arterial  trunks,  but  from  the  minute 
capillaries  in  which  these  arteries  terminate. 

Old  age  has  generally  been  regarded  as  a predisponent  cause  of 
apoplexy ; and  it  is  attended  with  two  circumstances,  which  are 
perhaps  not  altogether  without  reason  regarded  as  of  some  moment. 
The  first  of  these  is  the  venous  plethora,  so  ingeniously  maintained 
by  Cullen.  The  second  is  the  tendency  which  the  arterial  system 
more  especially  betrays  to  become  diseased  after  the  meridian  of 
life.  The  proofs  of  the  existence  of  venous  plethora,  and  the  theory 
of  its  operation,  may  be  found  in  Cullen,  who,  perhaps,  overrated 
its  influence.  There  is  little  doubt  that  the  circulation  in  the  veins, 
either  in  consequence  of  diminished  pressure  and  tension  of  the 
skin  and  other  coverings,  does  not  go  on  with  the  same  perfection  and 

* A Treatise  on  the  Diseases  of  Arteries  and  Veins,  pp.  25  and  26. 


BRAIN. 


303 


facility  with  which  it  does  in  early  life.  But  whether  there  is  a 
greater  venous  plethora  in  the  head  at  that  period  than  before  or 
not  seems  doubtful.  There  is  reason  to  believe,  that  the  fulness 
resides  as  much  in  the  arteries  as  in  the  veins.  It  is  manifest  also 
that  the  main  cause  of  this  venous  plethora  in  advanced  life,  viz. 
the  frequency  of  disease  of  the  heart,  especially  its  mitral  valve, 
and  of  the  aortic  valves,  Cullen  altogether  overlooked.  Of  the 
effect  and  reality  of  arterial  disease  I have  already  spoken. 

In  point  of  fact,  cases  of  apoplexy  occur  at  all  ages,  but  are  most 
frequent  between  the  50th  and  the  65th,  or  70th  year.  Willan  in- 
forms us  he  has  seen  young  persons  from  12  to  18  years  of  age 
affected  with  apoplexy  and  hemiplegia.  In  Bonetus  and  Morgagni, 
instances  of  apoplexy  are  found  occurring  in  persons  below  the 
age  of  30 ; but  in  general  they  were  induced  by  external  violence 
or  organic  diseases.  I have  seen  an  instance  of  cerebral  hemorrhage 
terminating  in  hemiplegy  in  a young  man  of  19,  labouring  under 
disease  of  the  left  auriculo-ventricular  orifice.  The  young  woman 
to  whose  case  I have  already  alluded,  was,  I think,  about  22 ; and 
in  general  when  the  disease  takes  place  between  18  and  30,  it  is  in 
consequence  of  disease  of  the  heart  or  its  valves,  or  of  the  aorta.  Of 
eighteen  cases  described  by  Bonetus,  five  occurred  in  persons  above 
60,  and  six  in  persons  below  40.  Morgagni  relates  the  cases  of 
thirty  apoplectic  persons,  seventeen  of  whom  were  above  the  age  of 
60,  and  five  below  that  of  40.  Of  thirty-one  cases  of  bloody  ex- 
travasation in  the  ventricles  or  the  substance  of  the  brain,  recorded 
by  Lieutaud,  one  was  at  the  age  of  25,  eight  between  the  ages  of 
30  and  41,  eleven  between  41  and  51,  six  betw'een  51  and  61,  two 
between  61  and  71,  twm  between  71  and  81,  and  one  only  above 
100.  Of  twenty-nine  cases  seen  or  dissected  by  Portal,  two  were 
between  19  and  23,  four  betw'een  30  and  41,  seven  between  41 
and  51,  eight  between  51  and  61,  four  between  61  and  71,  and  the 
same  number  between  71  and  81.  Of  6 cases  of  cerebral  hemor- 
rhage given  by  Cheyne,  three  were  between  30  and  35,  two  at  50, 
and  one  at  63.  Rochoux,  however,  has  given  the  fullest  and  most 
accurate  results  on  this  point.  Among  sixty-three  cases  of  apo- 
plexy, two  occurred  betw'een  the  age  of  20  and  30,  eight  between 
that  of  30  and  60,  seven  between  that  of  40  and  50,  ten  between 
that  of  50  and  50,  twenty-three  between  that  of  60  and  70,  twelve 
between  that  of  70  and  80,  and  only  one  between  that  of  80  and 
90.  According  to  this  view  apoplexy  is  extremely  rare  before  the 
30th  year  ; from  that  period  to  the  50th  it  is  not  common  but  may 


304 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


occur ; after  50  it  becomes  more  common ; between  60  and  70  is 
more  frequent ; becomes  of  the  same  rate  of  frequency  after  70  as 
before  60,  and  is  very  rare  after  the  80th  year.  Of  the  cases  given 
by  Lerminier  and  Serres,  though  two  are  between  30  and  35,  the 
great  part  are  between  60  and  75. 

The  state  of  the  cerebral  circulation  now  described  is  understood 
to  depend  exclusively  on  the  vessels  of  that  organ,  and  to  consti- 
tute, therefore,  primary  apoplexy.  . The  same  state,  or  a near  ap- 
proach to  it,  may  take  place  secondarily  in  at  least  two  different 
states  of  the  system  ; first,  as  a consequence  of  injuries  of  the  head ; 
and,  secondly,  in  the  course  of  fever  intermittent,  remittent,  or  con- 
tinuous. The  first  shall  be  considered  afterwards.  The  second, 
or  the  febrile  apoplexy,  belongs  to  this  place. 

a.  Apoplexia  Febricosa.  The  best  example  of  this  occurs  in 
certain  forms  of  ague,  accompanied  with  marks  of  great  accumu- 
lation in  the  head.  It  takes  place  chiefly  at  the  termination  of 
the  cold  stage,  and  the  commencement,  or  in  the  course  of  the 
hot.  In  a slight  degree  the  paroxysm  is  attended  with  drowsi- 
ness or  lethargy,  from  which  the  patient  may  still  be  roused. 
When  this  recurs  once  or  twice,  the  insensibility.is  more  complete, 
till  the  phenomena  of  perfect  apoplexy  are  induced.  In  other 
instances  after  dull  heavy  pain  of  the  head,  dizziness,  impaired 
vision,  and  some  affection  of  the  urinary  secretion,  the  individual 
falls  down  suddenly  with  the  mouth  open,  the  eyelids  fluttering, 
and  other  marks  of  relaxed  muscles;  and  continues  during  the 
rest  of  the  paroxysm  in  a stertorous  sleep.  This  may  cease  spon- 
taneously, or  terminate  in  death,  unless  the  paroxysm,  which  is 
generally  protracted  to  twenty-four  hours,  and  follows  the  tertian 
type,  is  finished.  Though  this  is  most  frequent  in  the  tertian,  it  is 
not  uncommon  in  the  quartan  and  quotidian. 

The  cases  examined  necroscopically  show  the  cerebral  vessels  to 
be  much  distended  with  blood,  sometimes  bloody  extravasation. 
In  other  instances  which  belong  to  a different  head,  the  distended 
vessels  are  accompanied  with  serous  effusion  between  the  membranes, 
or  within  the  cavities.  The  anatomical  character  of  soporose  ague 
is  therefore  inordinate  injection  of  the  cerebral  and  cerebro-menin- 
geal  capillaries. 

This  constitutes  in  various  degrees  the  sleepy  quotidian  (C.  Piso, 
Obs.  178,)  the  sleepy^  lethargic^  hemiplegic,  carotic,  and  apoplectic 
tertian,  (Werlhof,  Torti,  Lautter,  Morton,)  and  the  comatose  quar- 
tan (Piso,  Werlhof;)  and  is  the  disease  which  has  been  named  by 


BRAIN. 


305 


Baglivi*  and  Lancisi  f epidemic  apoplexy  {apoplexia  febricosa,  c&rus 
febricosus),  and  which  Morgagni  J and  Casimir  Medicus§  represent 
as  periodical  and  intermitting.  When  it  is  known  that  the  apo- 
plectic symptoms  are  regulated  by  the  motions  of  the  ague,  which 
alone  is  epidemic,  or  rather  endemial,  the  nature  of  the  periodical 
and  epidemic  apoplexy  is  easily  understood. 

These  soporose  agues  may  be  sporadic  or  general ; prevail  mostly 
in  the  summer  or  autumnal  months  in  warm  countries ; and  after 
a few  paroxysms,  sometimes  the  second  or  third,  are  generally  fatal. 
Their  mortality  is  so  uniform  that  they  have  been  named  death-fe- 
vers (Todten-fieber)  in  Germany  and  Hungary,  where  they  used 
to  be  very  common.  They  were  observed  at  Rhodes  by  Praxago- 
ras,  the  master  of  Herophilus;  afterwards  at  London  in  1678  by 
Sydenham ; at  Rome  and  in  various  parts  of  Italy  by  Baglivi  in 
1694  and  1695,  and  by  Lancisi  the  same  year,  and  at  Bagnareain 
1707 ; at  Hanover  by  Werlhof;  and  by  Cleghorn  in  Minorca. 

The  extravasations  into  the  cavities  of  the  brain,  observed  by 
Jackson  in  yellowfever,  belong  to  the  head  of  meningeal  hemorrhage. 

In  continued  fevers  of  this  and  other  countries,  apoplectic  death 
is  so  common,  that  I need  only  refer  to  the  works  of  Stoll,  Mills, 
Bateman,  Cheyne,  Barker,  and  Harty.  It  appears  to  be  at  once 
cerebral  and  meningeal. 

In  purpura  and  sea-scurvy  death  not  unfrequently  takes  place 
from  hemorrhage  within  the  brain,  or  on  its  surfaces.  The  latter 
is  most  common,  and  as  such  belongs  to  the  head  of  meningeal  he- 
morrhage. 

Apoplexia  Traumatica.  Traumatic  Apoplexy.  Apoplexy  from 
violence.  Hemorrhage  from  the  Cerebral  Membranes.  Traumatic 
Apoplexy.  Meningeal  apoplexy  of  Serres.  The  effects  of  injury  on 
the  skull,  especially  in  the  form  of  repeated  blows,  are  very  peculiar. 
One  blow,  of  course,  or  a fall,  in  which  the  skull  lights  on  a stone  or 
other  hard  body,  may,  as  it  often  does,  fracture  the  skull,  and  prove 
fatal  either  by  tbe  concussion,  cr  by  blood  effused  afterwards.  But 
there  is  another  class  of  cases  in  which  a series  of  blows  has  been  in- 
flicted on  the  head,  proving  fatal,  yet  without  fracturing  the  skull.  In 
the  class  of  cases,  also,  to  which  I now  refer,  the  patient  falls  into  a 

* G.  Baglivi  Dissertatio,  8vo.  De  Observationibus,  &c.  Appendix  de  Apoplexiis 
fere  epidemicis  proximo  elapso  biennio  in  Urbe  et  per  Italiam  Observatis.  Op.  Om. 
Antwerpice,  1715,  p.  683, 

t D.e  Noxiis  Paludum  Effluviis.  + Epist.  iii.  iv.  and  v. 

fcj  Geschichte  Periode-haltender  Krankheiten.  Erstes  Buch  ; Erstes  Capitel,  g ii. 

Peode-haltender  Schlagfluss,  p.  5.  Frankfurt  und  Leipzig,  1794. 

U 


306 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


state  of  insensibility  from  which  he  never  recovers ; and  this,  after 
lasting  from  40  or  50  minutes  to  two,  three,  or  more  hours,  termi- 
nates in  death. 

The  state  of  the  brain  is  in  such  cases  the  following. 

The  whole  surface  of  the  brain  under  the  site  of  the  blows,  and 
not  unfrequently  all  over,  is  covered  with  a layer  of  what  appears 
to  be  blood  of  considerable  thickness.  At  first  sight  this  appears 
to  be  outside  the  membranes.  But  on  examination  it  is  found  that 
the  blood  is  effused  or  infiltrated  into  the  subarachnoid  or  inter- 
membranous  tissue,  and  that  it  has  escaped  from  the  lacerated  ves- 
sels of  the  pia  mater.  The  thickness  of  this  layer  varies.  Some- 
times it  is  pretty  uniformly  spread  as  thick  as  a crown  piece  all  over 
the  upper  and  lateral  parts  of  the  hemispheres.  It  generally  in- 
creases in  amount  and  thickness  at  the  lateral  and  inferior  regions 
of  the  brain.  The  whole  posterior  lobes  and  the  cerebellum  may 
be  covered  by  it.  Most  usually,  however,  it  is  thickest  over  the 
crura.,  the  i liter cruralybssa,  the  annular  protuberance  and  the  me- 
dulla oblongata.  Over  these  parts,  in  two  fatal  cases  in  which  death 
followed  almost  immediately  repeated  blows  on  the  head,  I found 
the  blood  effused  into  the  intermembranous  tissue  over  the  base  of 
the  brain,  to  the  thickness  of  half  an  inch. 

This,  therefore,  is  a meningeal  hemorrhage. 

In  the  same  class  of  cases  blood  is  effused  within  the  ventricles 
often  to  a great  amount.  It  is  coagulated,  and  the  clot  is  surround- 
ed by  bloody  coloured  serum.  This  escapes  in  like  manner  from 
the  vessels  of  the  choroid  plexus  and  the  internal  pia  mater.  These 
appearances  are  so  uniformly  the  result  of  violence,  that  the  cir- 
cumstance of  their  situation  and  appearance  may,  along  with  other 
circumstances,  be  justly  inferred,  in  doubtful  cases,  to  prove  that 
death  is  the  result  of  violence.  The  fact,  therefore,  forms  a valu- 
able piece  of  evidence  in  medico-legal  inquiries,  to  prove  that  such 
hemorrhage  and  such  death  could  not  have  taken  place  from  inter- 
nal causes.  Attempts  are  often  made  either  by  ignorant  or  designing 
persons,  or  by  counsel,  to  prove  that  this  intermembranous  or  menin- 
geal hemorrhage  is  sanguineous  apoplexy.  The  answer  is  very  sim- 
ple but  decisive.  In  sanguineous  apoplexy  the  hemorrhage  always 
takes  place  in  the  substance  of  the  brain  and  lacerates  the  brain.  In 
traumatic  apoplexy,  or  that  from  violence,  it  takes  place  on  the  sur- 
face from  the  vessels  of  the  membranes,  and  compresses  the  organ. 

By  M.  Serres,  indeed,  a species  of  meningeal  apoplexy  has  been 
recognised  as  taking  place  spontaneously.  It  is  a very  rare  oc- 


BRAIN. 


307 


currence,  and  the  hemorrhage  is  in  general  on  the  free  surface  of 
the  arachnoid  membrane  ; in  other  words,  within  the  arachnoid 
membrane.  Collateral  circumstances  will  here  be  available. 

7.  Apoplexia  Neonatorum.  Among  the  cases  of  infants  expelled 
from  the  womb  lifeless,  or  in  such  a state  that  they  soon  cease  to 
live,  in  a considerable  number  the  appearances  are  the  following. 
A layer  of  blood,  mostly  coagulated,  but  with  some  bloody  serum 
oozing  from  it,  is  spread  uniformly  over  the  whole  of  the  superior, 
anterior,  posterior,  and  lateral  surfaces  of  the  hemispheres.  A si- 
milar layer  of  blood  is  found  extending  over  the  laminated  surface 
of  the  cerebellum.^  and  less  frequently,  perhaps,  over  the  base  of  the 
brain.  Within  each  lateral  ventricle,  and  sometimes  within  the 
third  and  fourth,  are  found  clots  of  blood  with  bloody  serum.  At 
first  sight,  it  might  be  thought  that  these  infants  had  been  born 
alive,  and  had  died  in  consequence  of  violence  inflicted  on  the  head. 
This  inference  is  not  quite  correct.  Violence  has  been  in  some  de- 
gree inflicted  ; but  it  is  the  violence  resulting  from  the  efforts  of  the 
uterus  in  forcing  a large  head,  or  a wrong  presentation  through  the 
pelvic  outlet ; and  the  infants  were  either  not  born  alive,  or  vital  ac- 
tion speedily  ceased.  Life  was  extinct  before  the  head  was  expelled, 
in  consequence  of  blood  effused  from  the  meningeal  vessels  into  the 
subarachnoid  tissue,  all  over  the  brain,  and  from  the  choroid ’plexus 
within  the  ventricles.  The  cause  is  most  commonly  protracted  and 
tedious  labour,  during  which  the  head  is  forcibly  compressed  against 
the  pelvic  bones ; and  the  hemorrhage  from  the  membranes  takes  place. 

This  is  the  apoplexia  neonatorum.,  or  apoplexy  of  new-born  in- 
fants, a lesion  almost  necessarily  and  invariably  mortal.  To  me 
it  appears  to  be  the  most  frequent  cause  of  still-births,  as  they  are 
termed  ; for  at  least  17  instances  in  20  that  I have  inspected,  in  the 
course  of  a long  series  of  yeai’s,  presented  the  appearances  now  spe- 
cified. To  understand  the  true  nature  of  this  lesion  is  important 
in  a medico-legal  point  of  view ; for  rash  and  ignorant  persons  have 
often  inferred,  that  it  was  the  effect  of  violence  intentionally  inflict- 
ed on  the  head  of  an  infant  born  alive.  Cruveilhier  gives  good  il- 
lustrations of  the  lesion,  and  the  history  of  several  cases  in  proof  of 
its  true  nature  and  origin.*  He  shows  that  all  infants  with  this 
lesion  are  not  still-born,  but  may  die  soon  after  birth;  that  it  is 
impossible,  in  all  cases,  to  determine  the  cause  of  death ; that  is, 
the  cause  of  the  hemorrhage ; but  that  cases  take  place  after  pre- 
sentation of  the  vertex,  of  the  hips,  of  the  chord ; and  after  long 

* Anatomie  Pathologique,  Livraison  xv. 


308 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


and  repeated  attempts  at  turning.  In  general  the  head  has  been 
too  slowly  born,  or  the  presentation  has  been  unfavourable. 

d.  On  a form  of  apoplexy  termed  nervous  much  has  been  said  by 
Zuliani  of  Brescia,* * * §  Kortum  of  Dortmund  in  Westphalia, -f-  and 
Kirkland  of  Ashby  de  la  Zouche  and  the  subject  has  been  re- 
vived by  Mr  Abernethy,§  and  Dr  W.  Philip.  In  this,  apoplectic 
symptoms  are  said  to  take  place  without  any  abnormal  state  of  the 
brain  or  its  vessels,  and  from  some  disorder  in  the  chylopoietic  or- 
gans, which  is  supposed  to  induce  a torpid  condition  of  the  brain, 
or  suspension  of  its  proper  energy.  It  may  he  doubted  whether 
satisfactory  proof  of  such  a state  has  yet  been  adduced.  Is^,  A 
fallacy  results  from  the  doctrine  that  hemorrhage  is  in  all  instances 
requisite  to  give  rise  to  apoplectic  symptoms.  I have  shown  that 
congestion,  injection,  or  distension  of  the  cerebral  vessels  is  adequate 
to  produce  this  effect ; and  whether  this  state  is  to  disappear,  re- 
main unchanged,  or  produce  serous  effusion,  or  bloody  extravasa- 
tion, so  as  to  remain  after  death,  will  depend  much  on  the  consti- 
tution of  the  individual  and  the  treatment  employed.  No  satisfac- 
tory conclusion  can  be  drawn  from  the  absence  of  hemorrhage  or 
serous  fluid.  2c?,  Disorder  of  the  chylopoietic  organs  is  an  acces- 
sory remote  cause,  which  may  operate  on  the  meningeal  and  cere- 
bral circulation.  3c?,  The  instances  adduced  as  examples  of  this 
disease  are  at  least  ambiguous.  The  fourth  case  of  Kirkland  can- 
not be  admitted.  The  case  of  Stark  (§  iv.  p.  73,)  I have  already 
mentioned  as  one  of  injection  either  of  the  spinal  chord  or  its  mem- 
branes. The  first  case  of  Dr  Powell  might  have  been  similar,  for 
the  spinal  chord  was  not  examined,  y In  other  instances,  as  in  that 
recorded  by  Morgagni,  (Epist  v.  17  and  19,)  one  in  the  meningeal 
vessels,  and  in  the  vascular  system  in  general,  might  have  been  the 
cause  of  death.  It  has  been  shown  by  M.  Serres,  that  many 
of  the  cases  of  supposed  nervous  apoplexy  must  have  been  examples 
of  what  he  terms  meningeal  apoplexy,  i.  e,  injection  of  the  menin- 
geal vessels  with  or  without  effusion  or  extravasation.  5?A,  In  other 
instances  a very  slight  and  incipient  degree  of  the  state  which  is 

* F.  Zuliani  De  Apoplexia  presertim  Nervea.  Lipsiae,  1780. 

+ C.  G.  Theod.  Kortum  Tremoni®  Westphali  dissertatio  de  Apoplexia  Nervofsa. 
Goettingae,  1785.  Ext.  in  Frank.  Dilectu,  Vol.  IV.  p.  1 ; et  Ludwig  Scrip.-Neur, 
Tom.  IV.  p.  379. 

+ A Commentary  on  Apoplectic  and  Paralytic  Affections,  &c.  By  Thomas  Kirk- 
land, M.  D.  1792. 

§ On  the  Constitutional  Origin  of  Local  Diseases. 

II  Medico-Chirurgical  Transactions,  Vol.  111.  By  Thomas  Chevalier. 


BRAJN. 


309 


to  proceed  to  pulpy  destruction  may  cause  death.  When  it  affects 
a whole  hemisphere,  which  it  may  sometimes  do,  (Morgagni,  Epist. 
V.  15,  16  ; li.  7, 1 1,)  it  may  alter  the  appearance  so  little  as  readily  to 
escape  observation.  Qth,  The  first  and  fourth  cases  of  Dr  Abercrom- 
bie I am  unable  to  explain ; but  I think  they  may  have  taken  place 
in  persons  with  granular  disease  of  the  kidney,  which  not  unfre- 
quently  causes  apoplectic  death,  yet  without  leaving  any  traces  of 
vascular  injection  or  hemorrhage. 

For  the  reasons  now  assigned,  it  may  be  justly  questioned  whe- 
ther there  is  ground  for  admitting  such  a state  of  the  brain  as  the 
nervous  apoplexy  of  Zuliani,  Kortum,  Kirkland,  and  Abernethy. 
According  to  the  present  state  of  evidence,  it  is  wisest  to  adopt  the 
side  which  does  not  recognize  this  form  of  apoplectic  disease. 

7.  In  the  foregoing  account  of  the  state  of  the  brain  giving  rise  to 
apoplectic  symptoms,  I have  said  nothing  of  that  loss  of  voluntary 
muscular  power  known  under  the  name  of  (^paralysis;  paresis; 
resolutio  because  I suppose  it  to  depend  on  the  same  state 

of  the  cerebral  capillaries  which  causes  the  general  apoplectic  af- 
fection, which  it  either  precedes,  accompanies,  or  follows ; or  on 
that  state  of  the  brain  or  spinal  chord  which  I have  already  de- 
scribed as  terminating  in  pulpy  destruction.  In  attempting  to  es- 
tablish clearly  the  anatomical  characters  of  palsy,  two  circumstances 
merit  particular  attention. 

First,  several  cases  of  apoplectic  death  are  preceded  by  paraly- 
tic affection  of  one  side,  more  or  less  extensive,  in  the  successive 
forms  of  distortion  of  one  side  of  the  face,  loss  of  speech,  loss  of 
power  in  an  arm,  a leg,  or  the  entire  side.  When  these  phenome- 
na are  followed  by  coma  and  death,  necroscopic  inspection  shows,  as 
in  apoplexy,  capillary  injection  with  or  without  extravasation,  and 
generally  more  or  less  destruction  of  brain.  The  commencement  of 
the  morbid  process  in  this  instance  is  doubtless  the  same  capillary 
injection  of  part  of  the  organ,  which  in  a more  exquisite  degree 
produces  the  comatose  state.  Secondly,  Though  there  are  not  a 
few  instances  in  which  an  attack  of  loss  of  consciousness,  sensation, 
and  motion,  is  not  followed  by  loss  of  voluntary  motion,  these,  I 
have  already  attempted  to  show,  depend  on  that  capillary  injection 
which  is  removable  by  the  use  of  remedies.  When  the  capillary 
injection  proceeds  to  destruction  either  by  hemorrhage,  by  soften- 
ing, or  by  ulceration,  i.  e.  by  superficial  pulpy  destruction  of  cere- 
bral substance,  consequent  on  hemorrhage,  It  almost  invariably 
leaves  after  it  more  or  less  loss  of  voluntary  motion,  generally  on 


310 


GENERAL  AND  RATIIULOGICAL  ANATOMY. 


the  side  of  the  body  opposite  to  that  of  the  brain  wliich  lias  sus- 
tained the  lesion.  One  of  the  most  frequent  effects  of  cerebral  he- 
morrhage and  its  consequences,  indeed,  is  palsy  of  the  hemiplegic 
form  ; and  in  the  brains  of  such  persons  as  have  laboured  under 
this  disease,  either  a broken  down  and  softened  spot,  or  one  or 
more  hemorrhagic  cavities  or  cysts  are  found  after  death,  (Wepfer, 
Willis,  Morgagni,  John  Hunter,  Baillie,  Wilson,  Abernethy,  Ro- 
choux,  Serres,  Lerminier,  Tacheron,  Abercrombie.)  The  general 
accuracy  of  these  conclusions  is  confirmed  not  only  by  the  necrosco- 
pic  appearances  of  the  brains  of  those  who  die  of  coma  succeeding 
to  palsy,  but  of  those  who  die  of  the  effects  of  injuries  of  the  head,  of 
abscess  of  the  brain  and  cerebellum,  and  of  tumours  and  other  or- 
ganic changes  taking  place  either  in  the  brain  or  in  its  membranes. 

I have  said  that  palsy  occurs  generally  in  the  side  opposite  to 
that  in  which  the  lesion  of  the  brain  is  found,  because  in  some  cases 
it  has  been  observed  in  the  same  side. 

Though  this  singular  phenomenon  early  attracted  the  attention 
of  pathologists,  it  cannot  be  said  that  the  circumstances,  under 
which  it  takes  place  or  does  not  take  place,  are  determined.  The 
fact  was  early  demonstrated  by  Molinelli ; and,  in  order  to  obtain  a 
satisfactory  explanation  of  it,  much  inquiry  and  experiment  was  un- 
dertaken by  Pourfour  de  Petit,  Saucerotte,  and  others,  members  of 
the  Academy  of  Sui’gery;  and  the  phenomenon  has  since  been  the 
subject  of  occasional  inquiry  to  several  from  Morgagni,  Haller,  and 
Prochaska,  to  Dr  Anderson  and  Dr  Yellowly.  The  mutual  inter- 
lacement of  the  cerebral  chords  between  the  restiform  bodies  has 
been  supposed  at  various  times,  from  Mistichelli  and  Pourfour  de 
Petit,  adequate  to  explain  it.  To  this  the  principal  objection  is  the 
fact,  that  palsy  of  the  opposite  side,  though  frequent,  is  not  an  in- 
variable result  of  injury  of  the  brain. 

The  situation  of  these  destroyed  spots  and  hemorrhagic  cavities, 
when  inducing  palsy,  corresponds  much  with  that  of  the  cerebral  in- 
jection or  hemorrhage  from  which  they  arise.  The  region  most  ge- 
nerally affected  is  that  already  described  as  the  striated  nwc/ewsof  Reil. 
Willis,  for  example,  states,  that  in  several  dissections  of  persons 
dead  after  long-continued  and  obstinate  palsy,  he  invariably  found 
the  corpora  striata  unusually  soft,  discoloured  like  wine-lees,  and 
with  the  usual  alternation  of  white  and  gray  streaks  much  oblite- 
rated.* The  accuracy  of  this  inference  regarding  the  part  of  the 

* Thoma;  Willis,  Cerebri  Anatome,  cap.  xiii.  p.  43,  et  De  Anima  Brutorum, 
cap.  ix.  p.  144  et  145. 


BRAIN. 


311 


organ  most  frequently  affected  is  confirmed  by  cases  given  by 
Petit ; by  several  of  those  given  in  the  Essay  of  ]\I.  de  la  Peyro- 
nie* * * § by  Antonio  Caldani ; by  Morgagni  in  repeated  observations 
both  of  paralytic  cases  terminating  in  coma,  and  of  those  originally 
apoplectic,  accompanied  with  distinct  palsy  ; (Epist.  xl.  2,  4,  6, 
11  ; li.  12  ; Ixii.  7,  9;)  by  three  cases  given  by  Prochaska  by 
Cheyne,  by  Rochoux,  by  Lallemand,  by  Tacheron,  (26,  27,  28,  29, 
30,)  and  by  Abercrombie,  (p.  252,  cases  112,  113,  114,  115.) 

On  this  point,  however,  the  remarks  already  made  on  the  seat 
of  cerebral  hemorrhage  are  applicable.  Though  the  striated  nu- 
cleus and  the  contiguous  part  of  the  hemisphere  forming  the  outer 
and  upper  walls  of  the  capsule,  are  the  most  frequent  seat  of  he- 
morrhagic cavities  and  pulpy  destruction,  other  parts  of  the  brain 
are  not  exempt.  In  the  work  of  Dr  Abercrombie  are  given  cases 
in  which  the  diseased  spot  was  nearer  the  surface  of  the  organ. 
(Ill,  116,  117,  118.)  I met  with  one  instance  in  which  hemiple- 
gia was  connected  with  pulpy  disorganization  of  the  posterior  part 
of  the  hemisphere,  so  near  the  convoluted  surface,  that  the  lesion 
could  be  immediately  recognized  after  removing  the  dura  mater, 
by  the  unusual  change  of  colour  and  consistence.  Dr  Duncan 
Junior  records  two  excellent  examples  in  which  pulpy  destruction 
of  the  anterior  and  middle  lobes  of  the  brain  caused  hemiplegy, 
and  that  of  the  cerebellum  gave  rise  to  palsy  of  the  paraplegic  form, 
without  disorder  of  intellect.^  It  appears  also  from  the  testimony 
of  Dr  Cheyne,  that  the  form  of  disease  which  he  terms  creeping 
palsy  depends  on  the  progressive  softening  of  the  substance  of  the 
hemispheres.  In  the  only  example  of  this  lesion  recorded  by  the 
author,  the  morbid  change  was  vascular  injection,  and  pulpy  de- 
struction of  the  white  matter  of  both  cerebral  hemispheres,  which 
was  of  the  consistence  of  thick  cream. § 

The  circumstances  of  cases,  in  which  this  change  takes  place, 
show  that  it  is  not  so  much  the  destruction  of  the  cerebral  sub- 
stance as  the  capillary  injection  or  inflammation,  with  which  it  is 
attended,  that  produces  the  loss  of  power  in  the  muscles  of  volun- 

* Observations  par  lesquelles  on  tache  de  decouvrir  la  partie  dii  Cerveau  ou  Tame 
exerce  ses  Fonctions.  Chez  Memoires  de  I’Academie  Royale  des  Sciences,  1741. 

Georgii  Prochaska  Op.  Minorum,  partem  ii.  Viemice,  1800.  Observat.  Patholog 
sect.  iv.  Casus  tres  co7nplectens,  die. 

f Contributions  to  Morbid  Anatomy,  Nq.  II.  By  A.  Duncan  Jun.  M.  D.,  &c. 
Ed.  Med.  and  Surgical  Journal,  Vol.  XVII.  328,  329. 

§ Dublin  Hospital  Reports,  Vol.  IV.  p.  270. 


312 


GENERAL  AND  PAI’HOLOGICAL  ANATOMY. 


tary  motion.  Tn  some  instances  of  paralytic  disorder  lasting  for  a 
considerable  time,  instead  of  finding  hemorrhagic  cavities  or  de- 
stroyed spots  in  the  bi-ain,  it  is  impossible  to  recognize  any  thing 
but  some  vascular  injection  and  effusion  of  serous  fluid,  which 
doubtless  proceeded  from  the  overloaded  vessels.  This  injection 
is  not  confined  to  one  spot,  but  is  diffused  in  different  degrees 
through  the  brain,  and  is  in  some  instances  strongly  marked  in  the 
cerebellum,  annular  protuberance,  and  tbe  meningeal  vessels  to- 
wards the  base  of  the  organ.  The  effects  which  this  state  of  the 
brain  produces  vai’y  somewhat  from  genuine  apoplectic  palsy. 
They  constitute  a double  but  unequal  bemiplegy  approaching  very 
gradually,  and  very  often  simulating  paraplegia.  From  this,  how- 
ever, they  differ,  in  the  lower  extremities  being  seldom  affected  in 
the  same  degree  and  at  an  equal  rate.  It  is  often  attended  with 
some  loss  of  memory,  or  sensation,  and  some  slight  degree  of  men- 
tal imbecility.  The  anatomical  character  of  the  disease  may  be 
represented  as  a chronic  congested  state  of  the  cerebral  capillaries. 
It  may  terminate  either  in  serous  effusion  from  the  meningeal  ves- 
sels, in  softening  of  the  cerebral  substance,  or  in  induration.  In 
the  first  instance,  it  belongs  to  the  head  of  meningeal  injection,  to 
be  afterw'ards  noticed.  In  the  second  case,  it  will  often  correspond 
with  the  creeping  palsy  of  Dr  Cheyne ; or  it  may  give  rise  to  epi- 
leptic attacks.  (Morgagni,  ix.  16,  18,  20,  23;  Greding,  No.  49, 
p.  494 ; No.  42,  p.  524  ; Wenzel,  Portal.)  In  the  third,  it  is  one 
of  the  morbid  states  of  the  brain  causing  insanity. 

8.  The  spinal  chord  is  liable  to  the  same  species  of  vascular  in- 
jection and  hemorrhage  which  takes  place  in  the  brain.  The  ca- 
pillaries, which,  in  the  sound  or  normal  state,  are  small,  and  convey 
almost  colourless  fluid,  become  enlarged  and  penetrated  with  red 
blood.  In  a stage  of  the  process,  which  is  to  be  regcirded  as  fur- 
ther advanced,  drops  of  blood,  and  occasionally  clots  of  some  mag- 
nitude, are  found  deposited  in  the  substance  of  the  chord.  These 
undergo  and  give  rise  to  the  same  changes  which  have  been  al- 
ready described  as  taking  place  in  the  brain,  and  are  a cause  by 
no  means  unfrequent  of  pulpy  disorganization  of  the  chord.  In 
the  case  given  hy  Gaultier  de  Claubry,  which  is  the  most  distinct 
on  record,  the  chord  opposite  the  seventh  cervical  vertebra  was  of 
a deep  red  colour  from  vascular  injection,  but  still  unbroken  in 
structure.;  from  the  seventh  cervical  vertebra  to  the  third  dorsal  it 
was  not  only  deep  red  on  the  surface,  but  on  the  substance,  and 


BRAIN. 


313 


so  soft  as  to  sink  under  the  knife  or  finger  ; and  from  the  third  dor- 
sal vertebra  to  the  lower  part  of  the  sacrum,  it  was  a red  blood- 
coloured  pulp  destitute  of  organization.*  The  cases  of  Chevalier, 
which  belong  rather  to  the  head  of  meningeal  hemorrhage,  shall 
be  noticed  afterwards. 

Pulpy  softening  of  the  spinal  chord  may  arise  either  spontaneously 
or  as  a consequence  of  injury,  more  especially  if  that  injury  causes 
fracture  or  even  concussion  of  the  vertebras.  When  it  takes  place 
spontaneously,  often  the  arteries  of  the  chord  are  previously  dis- 
eased. Most  commonly  the  appearance  of  the  chord  is  that  of  a 
pulpy  softened  mass,  falling  entirely  down  on  the  membranes  being 
divided.  In  extreme  cases,  the  chord  is  converted  into  a soft  se- 
mifluid diffluent  mass,  not  unlike  cream.  Sometimes  in  recent 
cases,  considerable  vascularity  and  injection  are  observed.  But  in 
chronic  cases,  the  vessels  are  in  general  scanty.  When  the  disease 
arises  spontaneously,  it  may  affect  a large  portion  of  the  chord. 

When  softening  is  the  result  of  injury,  as  contusion,  concussion, 
or  fracture  of  the  vertebrae,  it  is  in  general  limited  to  the  spot  where 
the  injured  bones  are  situate.  The  anatomical  and  physical  cha- 
racters are  the  same. 

The  effects  produced  by  capillary  injection  and  bemorrhage  in 
the  spinal  chord  vary  according  to  the  stage  of  the  process  and  the 
region  of  the  chord  in  which  it  occurs.  In  the  stage  of  injection  it 
produces  irregular  involuntary  twitches  of  the  muscles  of  the  trunk 
and  extremities,  numbness  and  coldness  of  the  skin  about  the  back, 
and  occasionally  of  the  limbs,  and  more  or  less  of  muscular  power. 
In  the  advanced  stage,  whether  that  of  hemorrhage  or  of  pulpy  de- 
struction, numbness  and  palsy  of  the  paraplegic  form  are  com- 
plete. 

In  some  instances  the  state  of  capillary  injection  appears  to 
give  rise  to  tetanic  symptoms.  This  fact,  which  was  observed  by 
Dr  Robert  Reid  in  Ireland,!  Duchatelet,!  Martinet,  and  Oilivier,§ 

* Journal  General  de  Medecinede  Chirurgie  et  de  Pharmacie,  &c.  12ieme  annee. 
Tome  XXXII.  A Paris,  1808.  P.  129. 

f On  the  Nature  and  Treatment  of  Tetanus  and  Hydrophobia.  By  Robert  Reid, 
M.  D.  Dublin,  1817. 

J Recberches  sur  ITnflammation  de  TArachnoide  cerebrale  et  Spinale,  &c.  Par 
M.M.  Parent-Duchatelet  et  L.  IMartinet.  Paris,  1821. 

§ De  la  Moelle  Epiniere  et  de  ces  Maladies,  <ftc.  Par  C.  P.  OUivier  d’Angers.  A 
Paris,  182-1.  Pp.  307,  308,  317,  349. 


314 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


in  France,  and  by  Dr  Duncan  Junior,  in  the  stage  of  suppuration,* 
has  led  to  the  recent  revival  of  an  opinion  originally  proposed  by 
Galen,  and  reproduced  in  modern  times  by  Fernel,  Willis,  and  Hoff- 
mann,— that  tetanus  depends  on  a morbid  state  of  the  spinal  chord 
or  its  membranous  coverings.  This  inference,  nevertheless,  is  not 
in  its  present  state  susceptible  of  that  degree  of  accuracy  which  en- 
titles it  to  a place  among  the  established  principles  of  pathology. 
Though  in  some  instances  capillary  injection  of  the  chord,  and  the 
origins  of  the  spinal  nerves  is  attended  with  tonic  spasms  of  the 
muscular  system,  in  a great  number,  perhaps  a larger  proportion, 
no  contractions  of  this  kind  take  place,  notwithstanding  every  mor- 
bid change  from  vascular  injection  to  pulpy  destruction  or  suppu- 
ration. Tetanic  spasms,  Ollivier  infers,  are  connected  with  the 
advanced  and  intense  forms  of  the  disease;  but  the  cases  collected, 
not  only  by  this  author  himself,  but  by  Pinel,  Velpeau,  and  Aber- 
crombie, show,  that  in  some  of  the  most  aggravated  forms  of  the 
disease  no  spasms  had  taken  place  till  the  last  few  hours  of  exis- 
tence. In  short,  the  circumstances  under  which  tonic  spasms  occur 
in  connection  with  vascular  injection  and  inflammation  of  the  chord, 
have  not  yet  been  distinctly  indicated.  From  the  cases  observed 
by  Reid,  Duchatelet,  and  Martinet,  Jones,  Ollivier,  and  Duncan 
Junior,  tetanic  spasms  appear  to  be  more  frequently  connected  with 
injection  of  the  membranes  than  of  the  substance  of  the  chord. 

The  variation  of  effects  according  to  the  region  of  the  chord 
affected  may  be  distinguished  into  three  heads as  the  morbid 
process  affects  the  longitudinal  extent,  the  transverse  breadth,  or 
the  antero-posterior  thickness  of  the  chord. 

a.  When  it  is  seated  in  the  upper  or  cranial  portion  of  the  chord, 
{meclullu  oblongata,)  the  effects  are  more  or  less  disorder  of  the 
senses,  locked-jaw,  gnashing  of  the  teeth,  impaired  articulation  and 
deglutition,  respiration  oppressed,  disordered,  and  panting,  palsy, 
and  death  by  asphyxia. 

When  it  is  seated  in  the  cervical  portion  it  gives  rise  to  tetanic 
rigidity,  convulsion,  or  palsy  of  the  muscles  of  the  neck,  more  or 
less  palsy  of  the  intercostals,  and  muscles  of  the  trunk  and  extre- 
mities in  general,  paralytic  weakness  of  the  diaphragm,  and  even- 
tually, as  this  advances,  death  by  suspension  of  the  mechanical 
agents  of  respiration. 

■*  Contributions  to  Morbid  Anatomy,  Case  5th.  Medical  and  Surgical  Journal, 
Vol.  XVII.  p.  332. 


BRAIN. 


315 


. In  the  dorsal  region  it  induces  convulsive  throes  of  the  trunk, 
palsy  of  the  intercostal  muscles,  with  short,  languid,  diaphragmatic, 
respiration,  palpita,tion,  and  irregular  throbbing  of  the  heart, 
hiccup,  squeamishness,  vomiting,  and  eventually  death,  partly  by 
impaired  respiration,  partly  by  failure  of  the  action  of  the  heart. 

In  the  lumbar  region,  palsy  of  the  lower  extremities  is  always  a 
prominent  symptom ; but  to  this  are  added  paralytic  retention  of 
urine  at  first,  afterwards  incontinence  and  involuntary  voiding  of 
the  contents  of  the  rectum. 

0.  The  transverse  diameter  of  the  chord  is  so  small,  that  in  ge- 
neral the  capillary  injection  and  its  consequences  are  not  confined 
to  one  side  only.  When  this  happens,  however,  which  is  rare,  it 
produces  hemiparaplegia,  or  palsy  of  the  lower  extremity  of  one 
side.  Though  this  has  been  so  frequently  observed  to  occur  on 
the  same  side  with  the  lesion  of  the  chord,  that  it  may  be  stated  as 
a general  result,  it  is  nevertheless  requisite  to  mention,  that  to 
Portal  we  are  indebted  for  a singular  case,  in  which  capillary  in- 
jection and  pulpy  destruction  of  the  right  side  of  the  lumbar  divi- 
sion of  the  chord,  gave  rise  to  palsy  of  the  left  inferior  extremity.* 

7.  To  the  antero-posterior  diameter  of  the  chord  the  same  ob- 
servations nearly  apply ; and  it  is  rare  to  find  the  anterior  part 
diseased  without  affection  of  the  posterior,  and  conversely.  In- 
stances of  this,  nevertheless,  have  been  observed ; and  it  is  inte- 
resting to  remark,  that  the  effects  which  respectively  result  from 
lesion  of  either  singly,  tended  to  confirm  those  inferences  which 
Charles  Bell  and  Magendie  have  drawn  regarding  the  anterior 
and  posterior  roots  of  the  spinal  nerves.  Thus  when  the  anterior 
part  of  the  chord  is  affected  without  the  posterior,  the  effect  is  loss 
of  muscular  power  more  or  less  complete,  while  sensation  remains. 
Conversely,  when  the  posterior  part  of  the  chord  is  injured  without 
the  anterior,  sensation  is  more  or  less  obliterated,  while  voluntary 
motion  is  little  affected.  Thus  in  a case  recorded  by  Dr  Jones, 
vascular  injection  of  the  posterior  surface  of  the  chord  impaired 
sensation  remarkably,  but  left  motion  little  affected.  | In  like 
manner,  in  a case  communicated  by  Royer-Collard  to  Ollivier, 
(Ohs.  47,  p.  334,)  pulpy  destruction  of  the  anterior  part  of  the 
chord,  from  the  restiform  and  olivary  eminences,  down  to  the  lum- 

* Anatomie  Medical,  Tome  IV.  p.  116. 

t Medical  and  Surgical  Journal,  Vol.  XXI.  p.  81,  83. 


316 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


bar  portion  without  affection  of  the  posterior,  caused  palsy  of  the 
. trunk  and  lower  extremities  without  impairing  sensation. 

9.  State  of  the  Brain  in  Fever.  A singular  state  of  the  brain  is 
observed  in  fever,  whether  typhus  or  ordinary  synochus,  which  usu- 
ally ends  in  typhus.  The  whole  of  the  convoluted  portion  of  the 
brain,  and  the  laminated  portion  of  the  cerebellum^  indeed  the  whole 
gray  matter  of  the  organ  acquires  a peculiar  deep  colour,  as  if  the 
gray  matter  had  been  tinged  of  a reddish-brown,  or  slight  pink- 
colour.  The  white  matter  is  also  redder  than  usual,  and  presents 
when  divided  numerous  dark-red  points  effusing  semifluid  dark- 
coloured  blood.  The  white  matter  of  the  crura  of  the  brain,  of 
the  protuberance,  and  the  bulb  of  the  spinal  marrow  (medulla  ob- 
longata), acquires  a peculiar  pink-colour,  totally  different  from  that 
observed  in  death  by  other  diseases,  and  similar  only  to  the  state 
of  the  brain  in  persons  destroyed  by  acute  or  chronic  asphyxia. 
The  membranes  are  generally  loaded  with  serous  fluid,  which  is 
also  found  in  the  cerebral  substance  and  within  the  ventricle. 
Brains  in  this  state  are  not  easily  preserved.  They  are  soft,  and 
lacerable,  and  generally  undergo  decomposition  early  and  speedily. 

This  state  is  manifestly  the  result  of  the  brain  being  supplied 
only  with  dark-coloured  or  non-oxygenated  blood.  With  this  its 
arteries  are  filled  during  life  and  after  death.  The  organ  is  indeed 
})oisoned  with  unrespired  blood,  much  as  if  the  individual  had 
breathed  carbonic  oxide  gas.  These  appearances,  which  depend 
on  the  quality,  not  the  amount  of  blood,  in  the  cerebral  vessels, 
have  been  ascribed  to  turgescence,  to  inflammation,  to  venous  con- 
gestion, and  everything  but  the  true  cause,  which  is  the  state  of 
the  lungs  and  blood,  already  noticed  in  Chapter  VII.  Section  II,  p. 

1 64.  Unarterialized  blood  is  sent  to  the  brain,  and  by  poisoning  sus- 
pends and  annihilates  its  functions.  Death  is  in  such  cases  pi’e- 
ceded  by  stupor  and  coma,  more  or  less  deep,  and  on  some  occasions 
by  fits  of  convulsions. 

10.  Malahencephalon.  Diminished  consistence  of  the  brain.  The 
change  above  described  in  the  consistence  of  the  brain  is  always 
accompanied  with  more  or  less  destruction  of  its  texture.  Under 
certain  circumstances,  nevertheless,  its  consistence  may  be  dimi- 
nished without  change  of  texture. 

The  natural  consistence  of  the  recent  adult  brain,  though  well 
known,  it  is  difficult  to  describe  in  exact  terms.  In  general  it  pos- 
sesses a degree  of  toughness  which  prevents  it  from  being  easily 


BRAIN. 


317 


divided,  unless  by  a very  keen  instrument ; and  after  incision  mi- 
nute fragments  are  left  on  the  sides  or  edge  of  the  knife.  A very 
thin  slice  of  white  cerebral  matter  is  sufficiently  tenacious  and  con- 
sistent to  sustain  its  own  weight,  and  to  admit  of  considerable 
stretching  without  being  broken  or  lacerated.  If  put  into  pure 
water  it  continues  unchanged  for  at  least  eight,  ten,  or  sometimes 
twelve  hours,  and  without  any  portion  of  it  being  either  dissolved, 
or  rendering  the  water  in  any  degree  turhid.  A newly  cut  surface 
of  brain  communicates  to  the  finger  a peculiar  clammy  or  viscid 
sensation,  in  consequence  of  which  it  moves  with  less  facility  over 
the  skin  of  any  opposite  surface. 

These  qualities,  the  existence  of  which  may  he  easily  demonstrated, 
pertain  especially  to  the  white  substance  of  the  adult  brain,  when 
death  takes  place  either  accidentally  or  by  an  acute  disease,  without 
direct  lesion  of  the  organ.  The  consistence  of  the  gray  matter  of 
the  convoluted  surface  is  inferior  to  that  of  the  white.  The  -white 
matter  of  the  twain-band  {corpus  callosum)  is  firm  and  tough  in  the 
direction  of  its  cross  fibres,  and  may  be  pulled  to  a considerable 
degree  without  giving  way.  The  cylindrical  fluted  masses  forming 
the  limbs  of  the  brain,  (crura,)  wbicb  consist  chiefly  of  white  matter, 
are  much  firmer  than  the  substance  of  the  striated  nucleus,  which  is 
mostly  gray ; and  the  annular  protuberance,  which  is  chiefly  white 
matter,  is  the  firmest  and  most  tenacious  part  of  the  organ.  The  cere- 
bellum, which  consists  chiefly  of  gray  matter,  is  invariably  less  firm 
than  the  brain  ; and  tbe  firmest  part  of  tbe  former  is  the  substance 
of  the  peduncles  and  the  white  matter  of  the  cerebellic  hemispheres. 
Of  the  spinal  chord,  the  cranial  part,  especially  the  olivary  emi- 
nences, are  the  firmest ; and  the  consistence,  though  less  than  that 
of  the  brain,  is  tolerably  uniform  to  the  lumbar  region,  in  which  it 
undergoes  a distinct  diminution,  and  finally  becomes  very  loose  in 
the  caudiform  expansion. 

The  degree  of  consistence  now  attempted  to  be  defined,  varies  at 
different  periods  of  life,  and  under  different  circumstances  of  health 
and  disease. 

In  early  life  the  substance  of  the  brain  is  very  different  in  con- 
sistence and  tenacity.  In  the  foetus  and  at  birth  its  softness  ap- 
proaches to  semifluidity.  Some  weeks  after  it  passes  from  a soft 
pulpy  substance  to  a state  of  greater  flrmness  and  tenacity  ; but  at 
the  distance  even  of  many  months  after  birth,  it  is  still  much  in- 
ferior in  these  qualities  to  the  brain  of  an  individual,  who  has  at- 


318 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


tainecl  the  fourteenth  or  fifteenth  year.  In  three  cases  of  infants 
cut  off  by  different  acute  diseases,  between  the  ages  of  20  months 
and  years,  I found  the  brain  soft,  compressible,  elastic,  but  not 
tough;  of  the  consistence  of  custard-pudding;  but  not  quite  so  firm 
as  to  bear  much  handling  or  stretching  without  being  broken  or 
torn.  In  several  cases  of  children  dead  between  the  7th  and  the 
11th  year  of  scarlet- fever  or  measles,  the  brain  was  firmer,  and  had 
acquired  greater  tenacity,  but  was  still  considerably  softer  and  less 
tough  than  the  brains  of  adults  who  had  attained  the  18th,  20th, 
or  22d  year.  Between  12  and  15  the  brain  in  general  acquires  a 
decided  degree  of  firmness  and  tenacity ; for,  though  still  highly 
elastic,  it  is  much  less  compressible,  and  much  more  distensible 
without  lacei’ation  than  before.  This  increase  of  firmness  and  te- 
nacity is  particularly  conspicuous  in  the  twainband  and  mesolobe,  in 
the  limbs,  in  the  optic  thalamus^  in  the  annular  protuberance,  and 
in  the  olivary  eminences.  It  is  impossible  to  say  when  the  organ 
may  be  said  to  attain  its  maximum  of  firmness.  But  after  the  22d 
year  I have  not  been  able,  in  a very  considerable  number  of  human 
brains,  to  recognize  much  variation  of  consistence  not  connected 
with  some  morbid  state,  either  of  the  system  at  large,  or  of  the  or- 
gan itself. 

In  extreme  old  age,  it  has  been  said  the  brain  generally  becomes 
firmer,  harder-,  and  dr'ier  than  in  the  meridian  of  life.  This,  I be- 
lieve, is  not  altogether  without  foundation ; though  it  is  doubtful 
how  far  this  is  to  be  r-egarded  as  a uniform  change,  independent  of 
disease  or  morbid  effects.  It  is  further  exceedingly  difficult  to  de- 
fine the  time  at  which  this  change  in  the  consistence  of  the  brain 
commences  or  is  accomplished.  In  persons  between  50  and  60,  I 
have  seen  the  brain  as  firm  as  in  others  between  70  and  80,  or 
above  that  age.  Conversely,  the  brain  is  found  sometimes  soft, 
even  in  persons  much  advanced  in  life. 

The  brain  of  the  adult  is  liable  to  lose  its  normal  consistence, 
and  become  preternatural ly  soft  in  chronic  diseases  of  emaciation, 
as  dropsy,  pulmonary  consumption,  and  other  pulmonary  disorders, 
mesenteric  wasting,  marasmus,  diabetes,  and  organic  diseases  in 
general.  The  diminished  consistence  now  remarked  is  most  fre- 
quently observed  in  dropsy,  diabetes,  and  pulmonary  disorders. 

In  the  first  the  brain  is  almost  invariably  soft  and  flaccid  through- 
out. It  cannot  sustain  itself,  but  falls  down  much  more  quickly 
than  in  the  natural  state.  It  is  not  easily  cut,  but  rather  gives 


BEAIN. 


319 


way  before  the  knife ; and  a portion  of  such  a brain  is  easily  lace- 
rated, and  falls  down  quickly  in  water.  This  diminished  consist- 
ence, which,  though  greatest  at  the  centre,  extends  through  the 
whole  organ,  depends  partly  on  the  deposition  of  the  proper  cere- 
bral matter  being  interrupted,  and  partly  on  the  admixture  of  se- 
rous fluid  with  its  minute  atoms.  The  texture  or  atomic  constitu- 
tion of  the  organ  is  not  altered. 

In  diabetes  a similar  change  takes  place,  chiefly  from  the  former 
cause. 

In  pulmonary  consumption,  whether  depending  on  chronic  bron- 
chial inflammation,  chronic  pleurisy,  or  on  tubercular  disorganiza- 
tion, the  brain  is  invariably  found  softer  than  natural.  When  the 
disease  which  induces  death  has  continued  long,  this  softness  is  very 
considerable,  and  amounts  almost  to  semifluidity.  It  may  then 
constitute  a true  cause  of  adventitious  disease.  This  state  of  the 
brain,  combined  with  a languid  and  retarded  motion  of  the  blood 
through  the  cerebral  capillaries,  may  be  the  pathological  cause  of 
the  delirium,  which,  either  alone  or  alternating  with  coma,  not  un- 
frequently  precedes  the  death  of  phthisical  patients.  The  cerebral 
capillaries  in  such  subjects  I have  found  large  and  numerous.  Is 
the  density  of  the  brain  diminished  ? Meckel  states  that  he  found 
a cube  of  six  lines  of  the  brain  of  a man  of  24,  cut  off  by  phthisis, 
to  be  Ij  grain  lighter  than  the  same  bulk  of  sound  brain. 

Confinement,  with  inactivity  and  low  diet,  tend  to  impair  the 
firmness  of  the  brain.  Thus  in  condemned  felons  and  others,  who 
have  been  imprisoned  for  some  time  previous  to  death,  either  vio- 
lent or  natural,  the  brain  is  found  unusually  soft.  Dr  Monro, 
tertius,  formerly  Professor  of  Anatomy  in  the  University  of 
Edinburgh,  who  has  had  numerous  opportunities  of  examining  the 
brains  of  persons  cut  otf  under  these  circumstances,  states  that  in 
criminals  in  general  he  found  the  brain  unusually  soft ; and  in  a 
young  man  otherwise  healthy,  who  was  put  to  death  for  piracy,  the 
brain  was  so  soft  that  it  gave  way  at  the  corpus  callosum.  The 
softness  appears,  from  the  account  of  Dr  Monro,  to  be  greater  in- 
ternally than  externally,  so  that  it  was  impossible  to  demonstrate 
the  deep-seated  parts  of  the  organ.*  In  opposition  to  this,  how- 
ever, I must  not  omit  to  mention  that  Littre  found  the  substance 
of  the  brain,  cerebellum,  and  medulla  oblongata,  unusually  compact 

* The  Morbid  Anatomy  of  the  Brain.  By  Alexander  Monro,  M.D.,  &c.  &c.  Vol.  I. 
Edinburgh,  1827,  p.  35  and  160. 


320 


GENERAL  AND  PATHOLOGICAL  ANATOBIY. 


and  dense  in  a felon,  who,  to  avoid  public  punishment,  killed  him- 
self by  dashing  his  head  against  the  wall  of  his  cell.  * * * § 

To  the  same  head  probably  is  to  be  referred  a form  of  diminish-  [ 
ed  consistence,  without  change  of  texture,  which  is  occasionally  oh-  j 
served  in  the  brains  of  persons  in  whom  chronic  encephalo-menin- 
sreal  congestion  caused  mental  derangement.  The  brain  in  fatu- 
ous  persons  appears  to  have  been  early  observed  by  Tulpius,  Ker-  ij 
kringius.  King,  and  Scheide,  to  be  soft  and  flaccid.  This  fact, 
which  was  repeated  by  Morgagni,  was  afterwards  verified  by  John 
Ernest  Greding  of  Waldheim,  who,  in  1771,  in  an  elaborate  de-  I 
scription  of  the  abnormal  changes  found  in  the  brains  of  epileptic 
maniacs,  states,  that  in  more  than  one-half  (fifty-one  cases)  the 
brain  was  either  universally  or  very  generally,  especially  in  its  jj 

central  parts,  unusually  soft  and  flaccid  ; and  that  though  this  may  i 

not  be  a uniform  cause  of  deranged  intellect,  it  is  a frequent  ac- 
companiment of  the  state  of  the  brain  on  which  this  depends.f  In 
twelve  cases  the  vault  and  septum  were  so  soft,  that  spontaneously 
or  by  a sliglit  touch  they  were  reduced  to  thin  pulp. 

Among  thirty-seven  cases  of  this  form  of  cerebral  disorder  in- 
spected by  Haslam,  in  seven  the  substance  of  the  brain  was  soft,  |: 

very  soft,  or  doughy  with  abundance  of  red  points,  the  usual  i 

indications  of  capillary  injection,  and  effusion  of  serous  fluid,  the 
effect  of  meningeal  injection,  j Among  the  dissections  of  Dr  Mar- 
shall,  not  more  than  one  belongs  to  this  head,§  (case,  6th  p.  202.)  'i 
This  change  depends  on  chronic  injection  of  those  capillaries  of  the  ; 
vascular  membrane  {pia  meninx)  which  are  distributed  through  the  j 
brain. 

11.  Sclerenheplialia.  Induration  of  the  brain. — That  the  brain 
may  acquire  an  unnatural  degree  of  firmness,  and  perhaps  of  den- 
sity, is  well  established  from  the  observations  of  Morgagni,  Meckel, 
Greding,  Haslam,  Marshall,  Serres,  Lallemand,  Lerminier,  Pinel 
Jun.,  Bouillaud  and  Gaudet.  Instead  of  the  usual  compressible 
elastic  character  which  it  presents  in  the  sound  state,  it  may  be- 

* Histoire  de  I’Acad.  Royale  des  Sciences,  An.  1705. 

-j-  MelanchoUco-Maniacorum  et  Epilepticorum  in  Ptochotropheo  Waldheimensi 
demortuorum  sectiones  tradit  Joannes  Emestus  Greding.  Cent.  2da,  Apud  Ludwig 
Adversaria,  &c.  Vol.  ii.  partem  3tiam,  p.  533. 

J Observations  on  Madness  and  Melancholy,  &c.  By  John  Haslam,  2d  edition,  i[ 
London,  1809.  Cases  4,  10,  18,  25,  28,  30,  37. 

§ The  Morbid  Anatomy  of  the  Brain,  &c.  London,  1815. 


ERAIN. 


321 


come  like  coagulated  or  boiled  albumen,  or  may  approach  in 
consistence  to  that  of  the  brain  which  has  been  immersed  in  strong 
alcohol  or  dilute  acid.  From  the  facts  hitherto  collected,  this  in- 
duration appears  to  be  of  two  kinds,  according  as  it  takes  place  in 
a shorter  or  longer  period. 

a.  According  to  the  facts  collected  by  Bouillaud,  a general  in- 
duration of  the  brain  may  take  place  within  ten  or  fifteen  days  be- 
fore death,  with  more  or  less  redness  and  injection  of  the  cerebral 
substance.  By  M.  Gaudet  this  change  is  conceived  to  be  one  of 
the  material  causes  of  ataxic,  (typhoid)  fever This  is  not  very 
widely  different  from  the  view  of  Bouillaud,  who,  like  M.  Brous- 
sais,  regards  it  as  the  result  of  meningo-encephalic  inflammation, f 

Notwithstanding  the  authority  of  these  observers,  I think  it 
doubtful  whether  this  change  can  be  supposed  to  take  place  in  the 
short  period  assigned  for  it  Is  it  not  more  reasonable  to  think 
that  this  change  hatl  pre-existed  for  some  time,  and  that  it  ter- 
minated in  a more  acute  disorder  of  the  organ  or  its  membranes, 
which  proved  fatal  ? 

13.  The  chronic  induration  of  the  brain  has  been  long  known. 
Originally  observed  by  Littre,  Geoffrey,  Boerhaave,  LancisI,  and 
Santorini,  it  was  recognized  by  Morgagni  as  a morbid  change 
which  occasionally  caused  more  or  less  mental  derangement. J J. 
F.  Meckel  afterwards  undertook  to  establish  this  doctrine  more 
fully,  and  to  show  that  the  organ  is  harder  and  more  elastic  than 
natural.  With  this  change,  however,  he  rather  paradoxically  con- 
nects another,  diminution  of  specific  gravity,  and  finds  that  a cube 
of  six  lines  of  indurated  brain  is  from  1-|  to  2 grains  lighter  than  a 
cube  of  the  same  size  of  sound  brain.  In  six  among  fifteen  cases 
given  by  this  author,  the  brain  was  much  firmer  than  natural ; in 
some  as  hard  as  indurated  white  of  egg,  and  always  elastic.  § 

This  result,  though  not  entirely,  is  partly  verified  by  the  re- 


* Recherches  sur  rendurcissement  general  de  I’encephale,  consideree  comme  une 
des  causes  materielles  des  fievres  dites  ataxiques,  par  M.  Le  Docteur  Gaudet.  Paris, 
1825. 

t Observations  et  Reflexions  sur  I’induration  generale  de  la  substance  du  Cerveau, 
consideree  comme  un  efiet  de  I’encephalite  generale  aigue,  par  M.  Bouillaud.  Ar- 
chives  Generales,  Tome  \dii.  p.  477. 

J Epistola  Anatomico-Med.  viii.  4 — 18. 

§ Recherches  Anatomico-Physiologiques  sur  les  causes  de  la  Folie  qui  viennent  du 
vice  des  parties  internes  du  corps  humain,  par  M.  Meckel.  Mem.  de  TAcademie 
Royale  de  Berlin,  Tome  vii.  p.  306,  art.  92.  Avignon,  1768. 


X 


322 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


searches  of  subsequent  inquirers.  Greding,  whom  I have  already 
mentioned  as  having  found  the  brain  in  a large  proportion  of  cases 
softer  than  natural,  found  it  in  thirty-nine  cases  natural  in  consis- 
tence, firm,  or  even  exceeding  the  natural  firmness.* * * §  He  thinks, 
however,  that  this  difference  is  more  in  word  than  reality.  Of  the 
thirty-seven  cases  inspected  by  Haslam,  in  nine  the  brain  was  un- 
usually firm,  in  one  (24)  remai’kably  so,  and  in  one  (29)  elastic.f 
In  all  the  cases  given  by  Dr  Marshall,  except  two,  again,  amount- 
ing to  fifteen,  the  brain  was  unusually  firm  and  generally  elastic.^ 
The  cause  of  this  change,  and  the  means  by  which  it  is  effected 
are  entirely  unknown.  It  is  conjectured  that  it  is  a result  of  in- 
flammation ; and  it  may  be  admitted  as  a proof  of  this,  that  the 
brain  is  almost  invariably  penetrated  with  numerous  loaded  capil- 
laries, and  that  more  or  less  effusion  of  serous  fluid  is  found  be- 
neath the  arachnoid  membrane  and  in  the  cavities.  These,  how- 
ever, might  be  effects  of  the  induration,  or  at  least  of  the  concomi- 
tant capillary  injection.  M.  Serres  has  seen  cases  of  cerebral  in- 
jection and  hemorrhage  causing  apoplectic  symptoms  terminate  in 
induration  ;§  and  Lallemand,||  Bouillaud,^  and  Pinel,**  have  found 
portions  of  the  brain  indurated  in  connection  with  chronic  inflam- 
mation. But  whether  this  is  to  be  viewed  as  the  result  of  capillary 
injection  or  of  some  derangement  in  the  process  of  nutrition,  it  is 
at  present  impossible  to  determine.  It  would  be  desirable  to  as- 
certain chemically  the  exact  nature  of  the  change  which  takes  place, 
and  in  what  respect  the  indurated  cerebral  matter  differs  from  that 
of  the  normal  state.  It  is  possible  that  the  albuminous  substance 
may  be  either  changed,  or  in  greater  proportion ; but  on  this  point 
no  accurate  observations  have  hitherto  been  made. 

Whatever  be  the  agent  or  means  of  this  change,  nevertheless, 
enough  is  known  to  show  that  when  it  exists,  it  is  in  general  ac- 
companied with  an  injected  state  of  the  cerebral  capillaries,  and 

* Adversaria  Medico-Practica.  Lud\vigf,  Tom.  ii.  p.  3ti»,  p.  533. 

t Observations  on  Madness  and  Melancholy,  &c.  Lond.  1809. 

+ The  Morbid  Anatomy  of  the  Brain,  &c.  Lond.  1815. 

§ Annuaire  Medico-Chirurgicale. 

II  Recherches  Anatomico-Pathologiques,  &c.  Lettre  2xieme,  cases  30,  31,  p.  3U.j 
and  313. 

U Traite  Clinique  et  Physiologique  de  PEncephalite,  Obs.  40,  p.  198. 

**  Recherches  d’Anatomie  et  de  Physiologie  Pathologiques  sur  les  Alterations  do 
TEncephale.  Bulletins,  &c.  chez  Revue  Medicale,  Tome  vi.  Paris,  1821,  p.  ,298  and 
31.5. 


BRAIN. 


323 


1 


that  it  gives  rise  to  loss  of  memory,  confusion  of  thought,  and  de- 
rangement of  the  mental  faculties.  It  appears,  indeed,  to  be  a fre- 
quent cause  of  insanity,  especially  when  permanent,  without  lucid 
interval ; and  if  long  continued,  it  may  cause  that  complete  obli- 
teration of  the  intellect  which  constitutes  fatuity  ; {dementia.)  The 
cerebral  arteries  are  generally  found  opaque,  and  affected  with 
steatomatous  deposition.  (Marshall.) 

From  slight  induration  of  a great  part  or  the  whole  of  the  cere- 
bral mass,  to  considerable  induration  of  particular  regions,  the 
transition  is  easy.  According  to  the  researches  of  INI.  Pinel  the 
younger,  who  has  examined  the  subject  with  particular  attention, 
in  the  change  from  sound  brain  of  natural  consistence  to  that  of 
final,  compact,  and  apparently  inorganic  induration,  two  distinct 
stages  may  be  recognized. 

a.  From  the  observations  of  MM.  Foville  and  Pinel-Grand- 
Champ,  it  results  that  in  certain  persons  the  exterior  or  peripheral 
part  of  the  brain  is  liable  to  a state  of  capillary  injection  or  chronic 
inflammation  ; in  other  words,  that  the  meningeal  and  encephalo- 
meningeal  capillaries  may  become  the  seat  of  a process  of  injection 
partly  chronic,  partly  intermittent,  or  variable,  according  to  the 
state  of  the  vascular  system  in  general,  and  the  operation  of  va- 
rious exciting  causes.  One  of  the  effects  of  this  encephalo-menin- 
geal  injection  is  to  tinge  of  a red  colour  more  or  less  deep,  the  gray 
colour  of  the  convoluted  surface  ; and  while  the  injection  produces 
more  or  less  mental  derangement,  this  red  tint  is  connected  almost 
invariably  with  furious  and  maniacal  paroxysms.  When  it  pro- 
ceeds to  fatuity,  albuminous  deposits  take  place  on  the  surface,  or 
on  the  membranes  of  the  brain  ; and  the  gray  substance  becomes 
very  pale,  and  softer  or  firmer  than  natural.* 

I have  above  said  that  the  subacute  or  chronic  cerebral  inflam- 
mation which  terminates  in  pulpy  destruction  is  a frequent  patho- 
logical cause  of  mental  derangement.  In  general  the  disease  is 
then  of  shorter  duration,  and  terminates  sooner  either  in  convales- 
cence or  in  death.  A more  chronic  form,  however,  is  connected 
with  this  encephalo-meningeal  congestion,  the  duration  of  which 
may  vary  from  twelve  or  fifteen  months  to  as  many  years.  At  the 
termination  of  these  periods  the  cerebral  substance  is  compact,  re- 
markably white,  appears  void  of  blood-vessels  and  capillaries,  is 

, • Recherches  sur  les  Causes  Physiques  de  PAlienation  mentale.  Par  M.  Pinel 

1 Fils,  D.  M.  P.  Journal  de  Physiologie,  Tom.  vi.  p.  44.  A Paris,  1826. 


I 


324 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


diminished  in  volume,  no  longer  falls  under  the  fingers,  but  is  torn 
with  difficulty,  and  recoils  with  elasticity  when  stretched.  It  as- 
sumes a horny  hardness  under  the  action  of  fire  or  nitrous  acid. 
These  circumstances  show  that  it  contains  altered  albuminous  mat- 
ter. The  gray  matter  also  is  thinner  and  paler  than  natural,  and 
seems  to  be  confounded  with  the  white. 

The  effects  observed  to  accompany  this  change  are  defect  and 
progressive  loss  of  memory,  inattention  to  momentary  impressions, 
apathetic  indifference  to  the  present  and  the  future,  and  slight  diffi- 
culty of  articulation,  followed  by  abolition  of  appetites,  desires,  and 
ideas,  increased  loss  of  speech,  palsy,  or  at  least  want  of  command 
over  the  muscles,  fatuity,  wasting,  and  death. 

That  this  change  in  the  consistence  of  the  brain  is  the  result  of 
a slow  organic  process  succeeding  to  inflammation,  M.  Pinel  infers 
from  the  symptoms  during  life,  from  the  collateral  effects  after 
death,  and  from  the  state  of  the  meningeal  and  cerebral  vessels 
which  is  known  to  precede  the  change.  That  this  is  not  remote 
from  the  truth  many  circumstances  tend  to  show.  I have  above 
mentioned  the  relation  between  hemorrhagic  injection  of  the  brain 
and  induration  as  noticed  by  M.  Serres  and  Bouillaud.  A proof 
still  more  unequivocal  is  found  in  the  fact,  that  inflammation,  both 
in  the  membranes  and  in  the  cerebral  substances,  is  known  to  be 
followed  by  induration  of  the  latter.  Thus  Abraham  Kaawe  Boer- 
haave  mentions  the  case  of  a soldier  cut  off  by  an  epileptic  at- 
tack, in  the  head  of  whom,  besides  firm  adhesion  of  the  dura  mater 
to  the  inner  table  and  the  pia  mater^  with  tubercular  deposition, 
the  subjacent  convoluted  gray  substance  was  hard  and  scirrhous  in 
various  places.*  The  cheese-like  induration  recorded  by  Lalle- 
mand  in  the  thirtieth  case  of  his  second  letter  is  adduced  elsewhere. 
Here,  however,  I may  mention,  that  in  a man  of  55,  in  whom  fixed 
pain  of  the  forehead,  slight  palsy  of  the  face,  and  confusion  of  me- 
mory were  soon  followed  by  death,  he  found  the  membranes  firmly 
matted  together  for  the  extent  of  a thirty  sous  piece  at  the  outerf 
end  of  the  left  hemisphere,  and  the  subjacent  cerebral  matter,  also 
adhering  to  the  membranes,  hardened  to  scirrhous  or  cartilaginous 
firmness. 

Lastly^  M.  Bouillaud  records  a case,  in  which  a man  of  68,  who, 

• Commentarii  de  Rebus  in  Scientia  Naturali,  Vol.  i.  Pars  i.  p.  234. 

-f-  Recherches  Anatomico-Pathologiques  sur  I’Encephale  et  ces  dejrondances,  par 
F.  Lallemand.  Paris,  1820,  p.  313. 


4 


BRALV. 


325 


after  cerebral  disease,  regarded  as  chronic  softening,  laboured  un- 
der impaired  memory,  headach,  and  difficulty  of  expressing  ideas, 
terminating  in  muscular  weakness,  and  fatal  convulsions.  In  this, 
with  injection  of  the  cerebral  substance,  was  induration  passing  from 
the  striated  body  of  the  left  hemisphere  through  the  nucleus,  at  the 
upper  region  of  which  it  formed  a cavity  with  hard  yellow  M'alls, 
and  a similar  hardened  portion  in  the  posterior  lobe.* 

The  disease  is  not  very  frequent  in  this  country.  One  very 
well  marked  case,  however,  came  within  the  sphere  of  my  observa- 
tion, and  was  inspected  by  me  after  death.  The  following  was  the 
state  of  the  hrain.  A considerable  portion  of  the  outer  part  of  the 
left  hemisphere  was  unusually  firm  and  hard,  not  dissimilar  to 
cheese.  The  space  so  changed  was  a sort  of  crescentic  segment  of 
the  hemisphere,  being  about  three-fourths  of  an  inch,  or  one  inch 
broad  in  its  middle,  which  corresponded  with  the  middle  of  the 
hemisphere,  and  tapering  away  to  a narrow  line  or  point  before 
and  behind.  The  induration  ascended  to  the  upper  part  of  the 
hemisphere  to  within  one  inch  of  the  mesial  plane  and  mesial  fis- 
sure, and  below  it  approached  close  on  the  hippocampus  major^ 
part  of  which  was  involved  in  the  induration.  The  indurated  seg- 
ment thus  formed,  was  bounded,  as  it  were,  between  the  segments 
of  two  spheres  of  unequal  diameter,  the  external  one  being  the  small- 
est or  of  greatest  curvature.  The  portion  when  divided  cut  firm,  and 
did  not  fall  down  or  dissolve  on  exposure  to  air.  The  pia  mater 
adhered  to  it  most  firmly,  and  seemed  to  be  thickened  over  the  in- 
durated portion.  The  convolutions  were  flattened  and  depressed, 
and  presented  in  this  respect  an  obvious  difference  . from  those  of 
the  opposite  hemisphere.  At  the  internal  margin  of  the  indurated 
portion  was  a band  or  zone  of  cerebral  substance  distinctly  soften- 
ed, while  within  that  again  the  rest  of  the  brain  presented  its 
natural  consistence.  The  indurated  portion,  both  gray  and  white, 
presented,  I thought,  very  few  small  vessels,  but  a few  large  ones 
dispersed  through  the  mass. 

Serous  fluid,  to  a small  extent,  was  effused  into  the  subarach- 
noid tissue,  mostly  at  the  apex  and  base  of  the  organ,  and  also 
within  the  ventricles. 

To  the  best  of  my  remembrance,  this  is  the  only  case  of  indura- 
tion of  the  brain,  in  which  that  lesion  was  associated  with  softening 


* Traite  Clinique  et  Physiologique  de  I’Encephalite,  Observ.  xL  p.  200. 


326 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


inside.  The  latter  I ascribe  to  a secondary  orgasm  or  vascidar  ac- 
tion caused  by  the  presence  of  the  indurated  portion,  nearly  as  the 
presence  of  tumours  is  occasionally  observed  to  induce  softening. 

In  this  case  the  individual,  a young  man  about  30,  had  long 
laboured  under  bad  health,  latterly  with  epileptic  fits  of  frequent 
recurrence.  The  last  time  T saw  him  alive,  he  was  dragging  his  legs 
in  a semiparalytic  manner,  had  an  expression  approaching  to  fa- 
tuous, did  not  readily  comprehend  what  was  said  to  him,  and  looked 
thin,  pale,  and  haggard  and  stupid.  He  had  consulted  or  been 
under  the  care  of  different  physicians,  all  of  whom  diflfered  more 
or  less  in  opinion  as  to  the  exact  cause  of  his  symptoms.  Between 
three  or  four  weeks  after  I saw  him,  he  fell  into  a stupid  and  co- 
matose state  and  died. 

From  these  and  similar  facts,  no  doubt  can  be  entertained  of 
the  tendency  of  the  process  of  inflammation  to  indurate  the  brain 
under  certain  circumstances.  The  difficulty  consists  in  ascertain- 
ing what  are  the  conditions  under  which  a process  usually  termi- 
nating in  softening  should  give  rise  to  an  opposite  change.  It  is 
probably  premature  to  attempt  any  explanation  of  a process  so 
contradictory  in  appearance.  I shall  merely  say,  that  induration 
seems  in  general  to  be  occasioned  by  the  encephalic  capillaries 
having  their  nutritive  action  so  much  injured  by  the  inflammatory 
process,  that  they  cease  to  deposit  healthy  cerebral  substance. 

The  induration  now  described  commences  generally  in  the  base 
of  the  brain  by  the  hippocampus  major,  {cornu  ammonisj)  and  these 
extends  to  the  neighbouring  parts.  If  confined  to  the  brain  only, 
it  causes,  according  to  hi.  Pinel,  mere  fatuity,  (dementia,)  with 
more  or  less  palsy.  But  if  it  affect  the  annular  protuberance,  the 
limbs,  or  the  olivary  bodies,  or  the  chord  itself,  epilepsy,  general 
palsy,  and  death  by  marasmus,  are  the  usual  consequences. 

b.  The  change  which  produces  fatuity  is  the  early  stage  of  a 
more  serious  lesion  of  the  cerebral  substance,  atropine  hardening, 
(sclerenhenplialia,)  an  extreme  state  of  induration  found  in  the 
brains  of  idiots.  From  that  already  described,  it  differs  chiefly  in 
degree.  A portion  of  brain  so  changed  becomes  a compact  inor- 
ganic looking  mass,  resembling  in  colour,  consistence,  and  density, 
indurated  egg  or  even  cheese.  The  cerebral  substance  is  depressed, 
shrunk,  and  condensed,  and  seems  utterly  void  of  vessels  or  ca- 
pillaries. When  exposed  to  the  action  of  fire,  instead  of  swelling 
up  without  odour,  and  leaving  a brownish  light  residue,  it  assumes 


BRAIX. 


327 


a horny  hardness,  emits  a strong  heavy  smell,  and  leaves  a com- 
pact shining  blackish  residue.  This  hardening  affects  the  white 
matter  more  than  the  gray,  in  which  ]\I.  Pinel  has  not  yet  recog- 
nized it,* * * § 

This  change  is  connected  with  idiocy  either  congenital  or  ob- 
served soon  after  birth,  in  some  instances  with  fatuous  stupidity  and 
palsy.  In  one  of  the  cases,  however,  the  individual  appears  to  have 
possessed  faculties  of  the  ordinary  degree  of  intelligence,  till  the 
age  of  49,  after  which  repeated  attacks  of  palsy  terminated  in  calm 
but  complete  fatuity,  (dementia.) 

That  the  spinal  chord  is  liable  to  the  same  change  in  consistence 
is  proved  by  the  case  of  Count  de  Lordat,  (Med.  Obs.  and  Inq. 
Vol.  III.  p.  270,)  and  that  of  M.  de  Causan,  recorded  by  Portal, 
in  which  the  cervical  portion  was  so  hard  as  to  resemble  cartilage, 
and  the  membranes  were  red  and  injected.  This  change  gave  rise 
to  palsy,  proceeding  fi-om  the  tingers  up  the  arms  of  the  right  side, 
and  from  the  feet,  till  the  legs  lost  power,  and  the  whole  side  be- 
came atrophied,  and  eventually  the  same  phenomena  in  the  left 
side.  Similar  examples  are  given  by  Bergamaschi.f 

\2.  Hypertrophy  of  the  Brain.  (Hypertrophia.)  Though  among 
the  writings  of  authors  on  morbid  anatomy  slight  notices  are  found 
of  the  lesion  characterized  as  hypertrophy  of  the  brain,  and  it  was 
mentioned  by  Bouillaud,  as  a peculiar  lesion,  it  was  not  made  the 
subject  of  special  observation,  until  M.  DanceJ  and  ]\I.  M.  Laennec,§ 
cousin  of  M.  R.  T.  Laennec,  and  M.  Scoutteten  in  1828,||  all  within 
a short  period,  gave  examples  of  it.  And  in  1835,  Dr  Sims  com- 
municated to  the  Medico-Chirurgical  Society  of  London  a memoir, 
containing  much  information  on  the  characters  and  nature  of  hyper- 
trophy and  atrophy  of  the  brain.  From  the  facts  given  by  these 
authors,  it  results,  that  the  brain  is  liable  to  undergo  a morbid 

* Recherches  de  I’Anatomie  Pathol,  sur  PEndurcissement,  &c.  par  M.  Pinel  Fils. 
Joum.  de  Ph}'sioL  Tome  ii.  p.  191. 

-f-  Sulla  Mielitide  Stenica,  &c.  Pa\ia,  1820.  2d.  4th,  8th. 

t Observations  pour  servir  a PHistoire  de  PHypertrophie  du  Cerveau.  Par  M. 
Dance.  Breschet,  Repertoire  Gendral  d’Anatomie  et  de  Physiologie  Pathologique, 
Tome  V.  p.  197.  Paris,  1828.  (Four  cases  in  adults  of  26,  24,  and  30  years  of  age.) 

§ Observations  sur  PHy'pertrophie  du  Cerveau.  Par  Meriadee  Laennec,  M.  D 
Revue  Medicale,  Decembre  1828.  (Five  cases,  a woman  of  32,  a woman  of  22,  a girl 
of  13  ; and  two  men  of  43  and  44,  both  white-lead  manufactiu'ers.) 

II  Observation  sur  une  Hypertrophie  du  Cerveau.  Par  M.  Scoutteten,  M.  D.  Ar- 
chives Generates  de  hledecine.  Tome  VIII.  p.  31.  (Case  of  a boy  aged  5i  years.) 


328 


GENERAL  AND  PATHOLOGICAL  ANATOMY, 


increase  in  nutrition,  distinguished  by  flattening  and  approximation 
of  the  convolutions,  narrowing  and  diminution  of  the  dimensions  of 
the  ventricles,  universal  firmness  and  whiteness  of  its  gray  and 
white  substance,  remarkable  dryness  of  its  parenchymatous  matter, 
and  of  the  cavity  of  the  arachnoid  membrane  ; while  the  texture  of 
the  organ  appears  not  to  be  sensibly  changed ; Id,  that  this  hyper- 
trophy is  constantly  observed  over  the  whole  encephalic  mass,  ex- 
cluding the  cerebellum  / and,  3c?,  that,  instead  of  increasing  the 
energy  of  the  cerebral  action,  it  tends,  on  the  contrary,  to  diminish, 
pervert,  and  suspend  that  action,  by  reason  of  the  compression  which 
it  necessarily  establishes  within  the  cranium. 

The  leading  anatomical  and  physical  characters  of  hypertrophy^ 
therefore,  are  the  following.  Increase  in  the  volume  of  the  brain, 
such  that  its  internal  substance  presses  forcibly  the  convolutions 
against  the  inner  surface  of  the  skull  and  against  each  other,  and 
thei’eby  flattens  and  depresses  these  bodies,  and  causes  them  to  ap- 
proximate ; while  the  same  internal  substance,  by  pressing  the  ven- 
tricles, diminishes  their  cavity.  Increase  in  weight  and  density,  which 
is  said  to  have  been  ascertained  in  all  the  cases,  the  specific  gravity 
being  increased.  The  substance  of  the  brain  is  also  firm,  as  much 
as  boiled  white  of  egg,  pale,  and  void  of  blood-vessels,  while  it  is 
unusually  dry.  From  all  these  circumstances,  it  results  that  this 
lesion  consists  in  the  deposition  or  addition  of  new  matter  in  the  in- 
terstitial tissue  of  the  brain  ; in  short,  a great  increase  in  nutrition. 

The  effects  and  symptoms  of  this  lesion,  though  always  present, 
are  not  uniform.  It  is  usually  preceded  or  attended  by  intense 
headachs,  subject  to  aggravation  ; an  obtuse  or  weakened  state  of 
the  intellectual  faculties,  perversion  of  these  faculties,  and  fits  of 
giddiness  accompanied  with  stupor.  Afterwards  accessions  of  con- 
vulsion repeatedly  take  place,  or  all  at  once  the  patient  suffers  a 
general  loss  of  sensation  and  motion.  The  pulse  is  slow ; the  tem- 
perature of  the  skin  natural.  Lastly,  the  patient  is  unexpectedly 
cut  off  in  the  course  of  an  epileptiform  accession. 

The  circumstances,  under  which  this  disease  is  developed,  are  not 
well  ascertained.  According  to  M.  Dance,  it  appears  to  take  place 
very  slowly  under  the  influence  of  very  obscure  causes.  M.  M. 
Laennec,  again,  thinks  that  it  is  developed  much  more  rapidly  than 
any  other  hypertrophy ; and  in  this  respect  he  allows  that  it  resem- 
bles the  lesions  of  inflammatory  character.  All  the  cases  given  by 
M.  Dance  took  place  in  adults.  One  case  given  by  Laennec  was 


BRAIN. 


329 


in  a young  girl  of  thirteen.  The  case  given  by  Scoutteten  took 
place  in  a cliild  of  five  and  a-half,  with  a head  so  large  and  heavy, 
that  whenever  the  child  attempted  to  run,  he  fell  forward  from  the 
great  weight  of  the  head.  Three  of  the  cases  given  by  Laennec  took 
place  in  persons  employed  in  white-lead  manufactories,  and  liable  to 
lead  colic  ; and  of  the  four  cases  given  by  M.  Dance,  two  occurred 
in  house-painters.  The  disease  had  not  then  been  observed  in  per- 
sons above  50.  In  most  of  the  cases,  the  patients  were  between  20 
and  30 ; in  two  cases  among  fourteen,  the  individuals  were  37  and 
39  years  of  age;  and  in  two  men  43  and  44  years  of  age. 

Andral  thinks  that  the  lesion  takes  place,  as  it  were,  in  two 
stages  or  periods ; that  in  the  first  the  disease  appears  like  a chro- 
nic affection,  with  headach,  hebetude  of  the  intellectual  faculties, 
and  similar  phenomena ; and  that  in  the  second,  which  is  attended 
with  epileptiform  convulsions,  it  presents  all  the  characters  of  an 
acute  and  speedily  fatal  lesion.* 

Dr  Sims  gives  the  details  of  fifteen  cases,  which  tend  partly  to 
confirm,  partly  to  modify  the  results  now  stated.  Among  these  fif- 
teen cases,  in  the  first  place,  the  ages  of  the  subjects  were  as  follow. 
One  at  1 1 months  ; one  at  3 years ; two  at  10  years ; one  at  16  ; one 
at  22  ; one  at  24 ; two  at  29  ; two  at  40  ; one  at  48  ; two  at  60 ; and 
one  at  70.  Of  none  of  the  cases  is  the  occupation  stated,  all  hav- 
ing been  occupants  of  the  St  Mary-le-bonne  Charity  Workhouse. 
Eleven  were  females  and  four  males.  Though  in  most  of  the  cases 
portions  of  the  brain  were  unusually  firm  and  consistent.  Dr  Sims 
extends  the  term  hypertrophy  to  cases  also,  in  which  the  brain  is 
unusually  large,  without  increased  consistence.  Dr  Sims  further 
recognizes  two  forms  of  hypertrophy ; one  a state  of  mere  enlarge- 
ment or  addition  of  particles,  without  appreciable  difference  from 
the  ordinary  state  of  the  organ,  congenital  or  connected  with  rickets, 
and  early  evincing  its  presence ; the  other  connected  with  increased 
weight  of  the  brain,  the  flattening  of  the  convolutions,  the  white  and 
albuminous  appearance,  and  tbe  bloodless  state  of  the  organ.  It  is 
chiefly  the  latter  form  of  the  disease  which  corresponds  with  that 
described  by  Dance,  Laennec,  and  Andral.  He  confirms  the  con- 

* Clinique  Medicale.  Par  G.  Andral,  il.  D.,  on  Choix  d’Observations,  &c.  Li\Te 
premier  ; Itrieme  ordre  ; 3ieme  edit.  1834.  Paris.  (Three  cases  ; a female  of  27,  a man 
of  29,  and  a man  of  39.) 

Case  of  Hypertrophy  of  the  Brain,  with  Spontaneous  Obstruction  of  the  Humeral 
Artery,  &c.  By  Dr  Christison.  Edin.  Med.  and  Surgical  Journal,  VoL  XLII.  p.  257. 
(A  female  aged  37,  Edin.  1831,)  published  1834. 


330 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


elusion  of  these  authors  that  the  change  affects,  so  far  as  is  hitherto 
known,  the  brain*  alone,  and  not  the  cerebellum  ; but  he  modifies 
their  inference,  that  it  affects  the  whole  organ.  Though  this  does 
take  place,  yet  hypertrophy  may  be  partial,  affecting  only  one  he- 
misphere, one  lobe,  one  corpus  striatum,  or  one  optic  thalamus.  He 
finds,  lastly,  that  the  brain  may  be,  in  certain  circumstances,  un- 
usually large,  yet  not  amounting  to  hypertrophy,  in  persons  dying 
of  various  diseases ; for  instance,  extensive  pneumonia  and  other 
diseases  of  the  lungs  and  heart ; and  then  the  brain  is  generally 
very  much  loaded  with  blood.* 

From  this  account  it  appears  that  cerebral  hypertrophy  differs 
little,  if  at  all,  from  what  is  above  described  as  induration  of  the 
brain. 

13.  Atrophy  of  the  Brain.  (^CerehrumEbriosorum;  Cerebrum  Biha- 
cium.')  The  Spirit-dr  inker's  Brain.  The  term  atrophy  is  employed  in 
two  senses,  something  different.  In  one  sense,  it  is  employed  to  in- 
dicate diminution  in  the  size  of  the  brain,  and  especially  of  its  convo- 
luted surface.  The  convolutions  are  shrunk,  small,  narrow,  and  occa- 
sionally soft ; the  sulci  are  large  and  open ; and  the  brain  recedes  from 
the  interior  of  the  skull;  while  the  subarachnoid  tissue  is  very  much 
loaded  with  serous  fluid,  which  has  the  appearance  of  a jelly  invest- 
ing the  whole  brain.  This  is  observed,  not  only  along  the  superior 
and  lateral  regions  of  the  hemispheres,  but  all  over  and  at  the  base 
of  the  bi'ain.  This  shrinking  of  the  brain  and  the  supplying  of  the 
place  by  fluid,  may  amount  to  the  thickness  of  about  one  crown- 
piece,  or  even  two  crown-pieces,  all  over ; and  in  some  extreme 
cases  the  shrinking  and  the  filling  with  serous  fluid  in  the  sub- 
arachnoid tissue  amounts  to  the  extent  of  half  an  inch  in  thickness. 

The  brain  is,  at  the  same  time,  very  soft  and  watery ; large 
quantities  of  fluid  escaping  both  from  the  convolutions,  when  the 
membranes  are  cut,  and  from  the  white  substance  of  the  hemi- 
spheres. The  ventricles  also  are  enlarged  and  capacious,  and  al- 
most constantly  contain  serous  fluid  in  considerable  quantity.  Much 
also  is  found  in  the  lower  part  of  the  brain,  and  escapes  from  the 
cavity  of  the  spinal  chord. 

This  is  general  atrophy  of  the  brain,  or  atrophy  of  the  convolu- 
tions ; and  it  is  supposed  to  depend  on  wasting  and  actual  loss  of 
the  cerebral  substance,  both  wdiite  and  gray,  while  the  place  of  the 
lost  matter  is  supplied  by  serous  fluid. 

* On  Hypertrophy  and  Atrophy  of  the  Brain.  By  John  Sims,  M.D.  Medico-Chi- 
riirgical  Transactions,  XIX.  315.  London,  1835. 


BRAIN. 


331 


This  is  one  mode  of  accounting  for  this  sort  of  atrophy ; and  it 
is  probable  that  to  many  examples  of  the  disease  it  correctly  applies. 
It  may  be  quite  true,  for  instance,  of  tbe  atrophy  taking  place  in 
old  age  and  in  various  enfeebling  diseases,  in  which  all  the  Organs 
suffer  more  or  less  waste  and  loss  of  substance  from  imperfect  nu- 
trition ; and  in  general  steatomatous  and  osteosteatomatous  disease 
of  the  arteries  of  the  brain.  This  form  of  atrophy  is  nevertheless  so 
frequent  in  persons  who  are  much  addicted  to  the  use  of  spirituous 
liquors,  to  whisky-drinkers,  gin-drinkers,  and  brandy-drinkers,  and 
is  so  common  in  those  who  have  either  had  delirium  tremens^  or  who, 
after-  a long  course  of  moderate  but  steady  di-inking,  have  died  either 
of  that  or  some  similar  affection,  that  the  shrunk  convolutions  and 
watery  state  may  be  regarded  as  characteristic  of  the  drunkard’s 
brain.  I do  not  say  that  atrophy  of  the  brain  does  not  take  place 
in  the  temperate.  But  it  is  so  constantly  observed  in  connection 
with  the  habit  of  incessant  drinking,  that  it  may,  in  a large  pro- 
portion of  cases,  be  considered  as  the  effect  of  that  habit. 

Local  forms  of  atrophy  are  also  observed.  Thus  portions  of  the 
convoluted  surface  may  be  depressed,  and  yellowish  and  covered 
with  fluid  within  the  membranes.  These  are  the  remains  of  some 
former  congestion  of  the  part.  The  surface  or  substance  of  one 
corpus  striatum  may  be  depressed  and,  as  it  were,  abraded ; or  the 
surface  of  one  optic  thalamus  may  be  less  developed  than  that  of 
the  opposite  side.  These  are  mostly  the  effects  of  some  previous 
attack  of  capillary  congestion,  sometimes  with  effusion  of  a little 
blood,  or  an  attack  of  softening  which  had  stopped  spontaneously. 

This  local  form  of  atrophy  has  been  examined  by  Dr  Sims ; and 
it  seems  quite  certain,  that  these  local  losses  of  substance  were  the 
effects  of  previous  attacks  of  disease.  Among  four  cases  fully  de- 
tailed, and  eleven  cases  noticed  by  this  author,  nine  took  place  in 
persons  above  70  years  of  age,  and  in  whom  they  were  associated 
with,  or  preceded  by,  attacks  of  cerebral  disease  of  different  kinds  ; 
and  two  were  observed  in  persons  above  60,  both  with  marks  of 
diseased  brain.  In  the  other  four  also,  though  young  persons,  very 
considerable  morbid  changes  of  different  kinds  had  taken  place  in 
the  brain  and  its  membranes.* 

Lastly,  the  term  atrophy  has  been  employed  by  Cruveilhier  to 
designate  that  extensive  deficiency  of  portions  of  the  brain  which 


* On  H^'pertrophy  and  Atrophy  of  the  Brain.  By  John  Sims.  Jledico-Chirurgical 
Transactions,  London,  Vol.  XIX.  p.  364.  London,  1835. 


332 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


takes  place  in  the  foetus,  in  consequence  of  diseased  action  during 
intra-uterine  life.  This  is  altogether  different  from  the  sense  in 
which  the  term,  as  above  explained,  has  been  employed ; for  the 
atrophy  in  the  cases  here  considered  is  not  congenital,  but  acquired 
in  the  progress  of  life.  The  atrophy  of  Cruveilhier,  on  the  other 
hand.  Is  congenital,  and  is  the  most  common  cause  of  idiocy.  As 
such  it  is  considered  under  the  head  of  Anencephalous  Malforma- 
tion or  Deficient  Brain,  (Enkephalelleipsis.') 

14.  Organic  changes,  morhid  growths,  or  tumours. — Of  these  va- 
rious forms  have  been  observed  by  different  authors.  But  they 
have  not  in  all  instances  distinguished  accurately  between  tumours 
originating  in  the  cerebral  substance,  and  those  which,  originating 
in  the  membranes,  affect  the  substance  of  the  organ  secondarily. 
As  this  distinction  must  be  observed,  at  least  in  pathological  ana- 
tomy, I shall  not  be  liable  to  the  charge  of  futile  innovation,  if  I 
attempt  to  trace  the  distinction  in  the  following  sketch. 

The  different  forms  of  tumour  occurring  in  the  brain  may  be 
referred  to  the  following  heads : a,  the  simple  cerebral  tumour ; (3, 
the  adenoid  or  fleshy  tumour  ; 7,  strumous  tumours,  comprehend- 
ing tubercles  and  tubercular  deposits ; S,  the  gelatiniform  tumour, 
(colloma ;)  s,  the  adipose,  lardaceous,  or  wax-like  degeneration,  (cc- 
roma ,-)  the  cholesterine  tumour,  (margaroides ;)  »j,  the  cartilagi- 
nous tumour,  (^chondroma;)  6,  calcareous  or  bony  deposits;  /,  en- 
cysted tumours,  including  o,  the  hydatid-cyst  or  vesicular  tumour, 
b,  the  blood  cyst,  (Jicernatoma,)  c,  the  fungoid  tumour,  and  iZ,  the 
melanotic  cyst. 

a.  Simple  cerebral  tumour.  {Scleroma.)  Of  considerable  indura- 
tion of  particular  regions  of  the  brain,  I have  already  spoken. 
When  the  indurated  portion  is  definite  in  limits,  and  the  rest  of 
the  organ  preserves  its  usual  characters,  these  indurated  portions 
have  been  vaguely  described  under  the  general  name  of  tumours. 
It  is  more  correct,  however,  to  regard  them  as  portions  of  brain 
indurated  to  an  unusual  degree,  and  perhaps  changed  in  intimate 
structure.  As  the  simplest  form  of  tumour  incident  to  the  brain, 
this  claims  the  first  place. 

Of  this  change  the  most  authentic  examples  have  been  recorded 
by  Platerus,  Meckel,  Roedei’er,  Perotti,  and  Greding.  From  the 
descriptions  given  by  these  authors,  part  of  the  cerebral  substance 
appears  to  acquire  unusual  firmness,  and  to  become  somewhat  like 
coagulated  albumen.  It  is  not  much  changed  in  colour,  unless  in 
losing  some  of  its  whiteness,  and  assuming  a pale  yellow  or  orange- 


BRAIN. 


333 


gray  tint.  The  surrounding  cerebral  substance  is  almost  invari- 
ably softened.  Water  is  effused  into  the  ventricles ; and  if  the  in- 
dm'ated  mass  is  seated  near  the  convoluted  surface,  the  membranes 
become  opaque  and  thick,  and  morbidly  adherent. 

The  following  references  to  the  cases  will  communicate  some  idea 
of  the  nature  of  this  change. 

Felix  Platerus,  Kb.  i.  p.  108. — In  the  fore  part  of  the  left  hemisphere  of  a man  of 
24,  who  had  headach,  amaurosis,  and  mental  imbeciKty,  a globular  tumour  like  a gland, 
as  large  as  a hen’s  egg,  but  irregular,  and  Kke  a pine  cone ; its  interior  substance  white, 
firm,  and  uniform,  Kke  boiled  egg,  but  harder,  inclosed  in  a firm  vascular  membrane. 
Weight  14  oz. 

Buonaventura  Perotti  in  Raccolta  d’OpuscoK  Scientifici  e Fisiologici  in  Venezia, 
Tom.  xlvK.  p.  339.  1751. — A woman  of  25,  who  had  headach  for  several  years,  died 

lethargic.  The  convoluted  gray  matter  of  the  left  hemisphere  was  destroyed.  In  the 
right  hemisphere,  though  externally  sound,  a hard  body  as  large  as  a nut  penetrated 
from  the  gray  to  the  white  interior  substance. — Commentar.  de  Rebus  in  Scientia  Na- 
turaK  et  Medicina  observatis,  Vol.  Ki. 

Meckel,  Mdmoires  de  I’Academie  Royale  de  BerKn,  1761.  Tom.  vii. — In  a man  of 
SO,  right  hemisphere  externally  harder,  more  resisting  and  more  elastic  than  natural. 
Left  hemisphere  before  the  same  ; posterior  lobe  soft  ; upper  posterior  part  of  left  he- 
misphere firm  ; pia  mater  opaque  and  thickened;  arachnoid  adhering  to  dura  mater ; 
substance  of  the  hemisphere  posterior  to  corpxts  striatum  soft,  diffluent,  and  moist  with 
fetid  serum.  In  the  posterior  part  of  the  left  hemisphere,  behind  the  ergot,  a hard 
body,  the  size  of  three  nuts,  consisting  of  three  spherical  protuberances,  aggregated  to- 
gether, weighing  2 oz.  and  2 drs. ; surrounding  substance  soft  and  pulpy. 

In  a child  of  4,  the  white  matter  of  the  posterior  lobe  of  the  left  hemisphere  a scir- 
rhus  (hardened  mass)  the  size  of  a nut ; surrounding  part  vascular  and  injected. 

Roederer,  J.  G.  Programma  de  Cerebri  Scirrho,  Goettingae,  1762.  This  after  some 
search  1 have  not  been  able  to  see. 

Vincenzio  GalK  negK  atti  dell’  Academia  deKa  Scienzi  di  Siena  delta  Fisico-critici, 
Tom.  K. — A man  of  40,  who  had  laboured  under  severe  cephalalgia,  which  was  reKeved 
by  venesection,  but  afterwards  recurred  irith  giddiness  and  delirium,  terminating  in 
death.  Inflammation  of  the  membranes  ; effused  serum  in  the  cavities  ; in  the  right 
ventricle,  stretching  from  the  optic  thalamrus  to  the  corpxts  striatum,  a tumour  as  large 
as  a hen’s  egg,  \vith  irregular  surface,  and  external  substance  dense,  firm,  and  ash- 
coloured. 

M.  Marcot,  chez  Memoires  de  la  Societe  de  MontpelKer,  Tom.  i.  p.  334.  Lyon, 
1766. — A man  of  47,  attacked  mth  giddiness,  headach,  impaired  fusion,  palsy  of  right 
side,  followed  by  paraplegia,  concisions,  lethargy,  and  apoplectic  death.  The  poste- 
rior part  of  the  brain  corresponding  to  the  tentorium,  to  the  branches  and  Kmbs  of  the 
vault  (fornix ),  was  scirrhous  and  almost  cartilaginous,  requiring  to  be  divided  by  good 
scissors,  and  grating  against  the  cutting  instrument. 

F.  Lallemand,  Recherches  Anatomico-Pathologiques.  Paris,  1820.  Lettre  2xieme, 
No.  30.  1820.^ — A girl  of  14,  ivith  right  hemiplegj’,  followed  after  four  months  by 

paraplegjq  uisensibiKty  of  the  skin,  palsy  of  the  sphincters,  and  paralytic  dyspnoea  ad- 
vancing progressively  to  fatal  asphyxia.  The  white  matter  of  the  left  hemisphere, 
immediately  above  the  lateral  ventricle,  for  the  space  of  1 ^ inch  long,  1 inch  broad, 
and  2 or  3 Knes  thick,  converted  into  a hard  substance  Kke  Gruyere  cheese,  and  re- 
sisting the  knife. 

Dr  Abercrombie,  Researches,  &c.  p.  431.  Notes. — In  a child  of  4,  unable  to  walk. 


334 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


with  imjjei'fect  articulation,  deficient  intelligence,  difficult  deglutition  and  respiration, 
and  frequent  convulsions,  terminating  at  the  end  of  eighteen  months  in  death,  the  oli- 
vary bodies,  peduncle  of  the  cerebellum,  and  mammillary  eminence,  were  in  a state  of 
cartilaginous  hardness. 

M.  Andral  Fils,  Journal  de  Physiologic,  Tome  ii.  p.  111.  1 822. — In  a girl  of  about 

20  months,  with  alternate  motion  of  the  head  to  the  right  and  left,  terminating  in  fatal 
coma,  without  convulsion  or  palsy,  several  of  the  convolutions  of  both  hemispheres  had 
become  extremely  hard,  and  assumed  the  colour  of  ivory;  When  pressed  between 
the  fingers  they  resisted  like  fibro-cartilage  ; when  drawn,  they  recoiled.  Similar  in- 
durations were  found  in  the  substance  of  the  liemisirheres  to  their  base.  The  right 
hemisirhete  of  the  cerebellum  contained  a round  cyst  uith  smooth  walls,  of  the  capa- 
city of  a nut,  containing  minute,  hard,  irregular  shaped  concretions,  of  strong  consis- 
tence, and  similar  to  the  spiculre  of  a fractured  bone. 

M.  J.  Bouillaud,  Traite  de  I’Encephalite.  Paris,  1825.  P.  161,  Obs.  33. — A man 
of  57,  with  impaired  sireech,  after  a cerebral  disorder  ; in  the  anterior  lobe  of  the  left 
hemisphere  an  albuminous  mass,  the  size  of  an  egg,  sprinkled  with  drops  of  blood,  and 
drops  of  purulent  fluid. 

Ibid.  Observat.  36,  p.  183. — A man  of  57,  wnth  right  hemiplegy,  intellectual  imbe- 
cility, and  involuntary  reiretition  of  the  last  words  siroken  to  him,  after  an  apoplectic 
attack,  terminating  in  complete  fatuity^  and  death,  rvith  injection  of  the  membranes 
and  cerebral  substance,  in  the  anterior  third  of  the  left  hemisphere  was  found  an  in- 
durated nut,  the  size  of  an  egg,  surrounded  by  bloody  clots  and  distinct  injection.  A 
longitudinal  section  presented  yellowish  colouring  and  red-broum' points,  depending  on 
the  presence  of  blood  coloured  with  the  substance  in  which  it  was  effused.  The  sub- 
stance of  the  indurated  mass  resembled  concrete  pus  mixed  with  blood,  grating  under 
the  knife,  and  containing  minute  bloody  effusions  with  filamentous  substance,  and, 
though  much  firmer'  than  the  rest  of  the  brain,  falling  easily  under  the  finger.  It  was 
separated  from  the  surrounding  brain  by  a circle  of  well  injected  capillaries.  In  the 
middle  lobe  of  the  same  hemis]5here  was  a similar  mass,  less  extensive,  and  rather 
softened  than  indurated. 

This  appears  to  be  an  albuminous  tumour  in  its  early  stage. 

In  the  following  cases  the  diseased  change  was  found  in  the  ce- 
rebellum. 

Joannis  Harder!,  Apiarum  Basilese,  1687.  4to.  Observat.  58,  p.  238. — A girl  of 
17,  of  scrofulous  habit,  who  suffered  severe  lancinating  pains  of  the  head,  followed  by 
fatal  convulsions.  The  membranes  containing  much  yellow  serum  ; vessels  minutely 
injected  ; in  the  cerebellum,  near  its  termination,  three  hard  globular  bodies,  (scirr/w,) 
one  as  large  as  a nutmeg  in  the  beginning  of  the  spinal  chord.  They  contained  yel- 
lowish matter  of  considerable  consistence. 

Ephemerides  Naturte  Curiosse.  Decade  iii.  Ann.  iv.  p.  148. — In  a hydrocephalic 
subject,  the  cerebellum  indm-ated,  adhering  to  the  dura  mater  and  skull  without  inter- 
mediate cavity. 

J.  Mar.  Lancisi,  De  Noxiis  Paludum  Effluviis,  Lib.  ii.  Eqiid.  iii.  c.  vi.  21 8. — In  the 
cerebellum  of  a man  subject  to  convulsions,  cut  off  by  intermittent  fever,  was  a hard 
white  body,  two  inches  broad  and  three  long,  composed  of  several  globular  masses 
aggregated,  invested  with  membranes. 

Memoires  de  I’Academie  Boyale  des  Sciences,  1705,  No.  13. — In  a boy  of  44,  who 
was  stupid  for  two  years  before  death,  the  cerebellum,  with  the  posterior  half  of  the 
medulla  oblongata,  (the  restiform  bodies?)  was  changed  into  a hard  white  homoge- 
neous mass. 

Morgagni,  Epist.  Ixii.  15. — A man  aged  48,  pursuing  the  occupation  of  a cook,  and 


BRAIN. 


335 


exposed  to  charcoal  fmnes,  laboured,  for  a year  before  death,  under  acute  pains  of  the 
head,  and  weakness  of  the  lower  extremities,  which  terminated  in  paraplegy,  rvithout 
affection  of  the  arms,  finally  became  soporose  during  the  day,  with  slight  raving  at 
night,  and  with  lucid  intervals,  and  died.  The  cerebellum  was  hard  to  the  knife.  In- 
stead of  the  usual  apjiearance  of  ramified  arrangement,  which  had  disappeared,  was 
one  of  parallel  white  streaks,  firm,  (scirrhosa,)  of  a uniform  colour,  approaching  to 
pale  carnation  ; and  when  minutely  examined  appearing  to  consist  of  roundish  atoms, 
mutually  aggregated,  without  membrane  or  blood-vessel.  This  change,  which  affect- 
ed the  whole  left  hemisphere,  encroached  a little  only  on  the  right. 

La  Peyronie,  Memoires  de  I’Academie  Ro)mle  des  Sciences,  1741.  P.  208,  4to, 
283,  12mo. — A man  of  30,  who  for  ten  years  passed  for  a melancholy  hypochondriac, 
complained  during  the  three  last  months  of  life  of  weight  and  pains  of  the  head  to- 
wards the  occipital  region  and  neck  ; had  conruilsions  about  half  an  horn-  in  all  the 
members  ; and  two  days  after  perished  in  a fresh  attack,  lasting  only  a quarter  of  an 
horn’.  Attached  to  the  fourth  ventricle  was  a hard  tumour  as  large  as  a hen’s  egg, 
occupying  the  place  of  the  cerebeUiuu,  which  was  reduced  to  a glairy  membrane  as 
thin  as  a hne,  investing  the  tumour.  This  tumour,  which  compressed  the  tubercula 
quadrigemina,  appears  to  have  been  attached  to  the  choroid  plexus  of  the  fourth  ven- 
tricle, and  probably  grew  from  it  originally. 

Brisseau  mentions  a hard  tumorrr,  as  large  as  a pigeon’s  egg,  in  the  middle  of  the  ce- 
rebellum, producing  palsy. — Obs.  iii.  p.  27. 

From  this  list,  which  contains,  if  not  the  whole,  at  least  the  most 
authentic  cases  of  this  form  of  cerebral  tumour,  it  may  he  inferred, 
that  it  consists  in  a portion  of  hrain  becoming  unusually  hard,  as- 
suming a white  or  yellow  white  tint,  and  in  losing  much  of  its  ap- 
pearance of  organization,  especially  fibrous  structure  and  vascular 
ramification.  The  hardness  of  these  tumours  varies  from  that  of 
granular  cheesy  matter  to  firm  indurated  albumen.  Of  some  the 
structure  is  said  to  be  fibrous ; hut  in  such  cases  the  fibrosity  of 
sound  cerebral  substance  is  not  meant.  In  the  presence  of  a cap- 
sule or  a vascular  spherical  shell  there  is  some  variation,  which 
seems  to  depend  on  the  stage  of  growth  which  the  tumour  has  at- 
tained. If  recent,  it  is  generally  surrounded  by  such  a vascular 
cyst.  If  of  long  standing,  it  is  generally  surrounded  with  a layer 
of  softened  brain,  the  result  of  the  vascular  irritation  established  in 
the  confines  of  of  the  tumour. 

Adenoid  or  fiesh-like  tumour.  {Adenoidea.)  To  the  second 
head  may  be  referred  a sort  of  tumour  which  has  been  described 
sometimes  under  the  vague  name  of  scirrhus  ; sometimes  under  that 
of  scrofulous  tumour ; but  which  cannot  be  admitted  to  possess  un- 
equivocal characters  of  either.  It  is  generally  described  as  similar 
to  a mass  of  flesh,  or  an  enlarged  absorbent  gland.  Its  colour  is 
light  pink  or  pale  flesh-colour ; its  firmness  is  considerable ; and 
in  some  instances  it  is  compared  to  the  kidney.  To  this  head  be- 
long the  following  cases  : — 


336 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Felix  Plateius  Observation.  Lib.  i.  p.  13. — A military  man  of  equestrian  rank, 
who  had  for  two  years  laboured  under  mental  derangement,  ndth  much  loss  of  memory 
and  natural  appetites,  and  with  frequent  somnolence  at  table,  at  length  expired.  Up- 
on the  mesolobe,  upon  separating  the  hemispheres,  was  found  a remarkable  globular 
tumour,  fleshy  like  a gland,  hard,  but  spongy  (fungosua),  of  the  bulk  of  a moderate 
pippin,  enclosed  in  a proper  tunic,  vascular,  and  free  from  all  connection  with  the 
brain. 

Did  this  originate  in  the  pia  mater,  in  which  it  appears  to  have  been  enclosed  ? 

Joannes  Rhodius,  Centuria  i.  Observat.  55. — In  the  ventricle  of  the  brain  of  a noble 
Bolognian  a fleshy  tumour  gave  rise  to  epileptic  fits. 

Miscellanea  Curiosa. — In  the  substance  of  the  brain  a tumour  like  a strumous 
gland.  • 

Johan.  Jac.  Wagner,  Miscellan.  Curios.  Dec.  ii.  Ann.  10. — A boy  of  14,  suffering 
pain  in  the  forehead  and  occipital  region  near  the  junction  with  the  vertebraj,  coming 
on  in  paroxysms,  relieved  by  vomiting  ; epileptic  symptoms  and  death.  In  the  white 
matter  of  the  posterior  part  of  the  brain  (occipital,)  a preternatural  hard  sebaceous 
gland,  friable  ; in  the  convolutions  of  the  anterior  lobe  two  glands  ; in  the  end  of  the 
cerebellum,  near  the  calamus  scriptorius,  one  as  large  as  a walnut. 

Memoires  de  I’Academie  Royale. — In  the  right  corpus  striatum  a glandular  substance 
the  size  of  a bean. 

Joh.  Gottfr.  Zinn.  apud  Comment.  Soc.  Reg.  Scientiarum  Gottingensis,  Tom.  ii.  1752. 
— In  an  infant  affected  with  enlarged  lymphatic  glands  a hard  substance  as  large  as  a 
walnut.  Of  this,  however,  he  neglected  to  preserve  an  accurate  account. 

In  another  infant,  part  of  the  left  hemisphere  of  the  cerebellum,  to  the  extent  at 
least  of  two  inches,  was  converted  into  five  hardish  bodies  of  different  sizes,  yellow,  like 
hardened  Ijonphatic  glands,  mutually  adhering.  In  some  parts  the  traces  of  the  circu- 
lar leaflets  of  the  cerebellic  plates  was  left  ; in  others  they  had  disappeared,  and  left  a 
uniform  inorganic  mass.  The  pia  mater  was  readily  detached,  except  at  the  middle  of 
the  hard  mass,  where  it  adhered  so  firmly  that  it  could  not  be  removed  without  lacera- 
tion. The  contiguous  vessels  were  injected. 

In  an  adult  female,  he  observed  beneath  the  parietal  bone  in  the  convoluted  part  of 
the  brain  three  similar  hard  bodies,  each  as  large  as  a nutmeg.  They  adhered  to  the 
dwra  mater  ; and,  in  all  probability,  they  originated  in  that  membrane. 

Haller,  Opusc.  Pathol.  Obs.  1. — In  a beggar  girl  of  six  years,  with  enlarged  mesen- 
teric, inguinal,  and  bronchial  glands,  the  left  hemisphere  of  the  cerebellum  was  found 
adhering  to  the  occipital  dura  mater  ; the  whole  substance,  white  and  gray,  changed 
into  a hard  mass  two  inches  in  diameter  on  both  sides,  uniformly  thick,  fibrous  like  the 
kidney,  flssOe,  destitute  of  vessels,  and  without  remaining  trace  either  of  gray  matter 
or  of  white  ramification. 

John  Jac.  Huber,  Nova  Acta  Physico-Medico  Academ.  Ctesarece  Leopoldino-Caro- 
linas,  Tom.  iii.  p.  533  ; also  Comment,  de  rebus  in  Scientia  Natural!,  Vol.  xviii.  p.  335. 
—In  the  brain  of  a boy  of  3,  cut  off  by  decay  {tahes),  a hard  glandular  tumour  of  the 
size  of  a filbert,  in  colour,  hardness,  and  other  qualities  like  a lymphatic  gland.  When 
divided  it  was  found  to  consist  of  a thin  coat  enclosing  a hard  nucleus,  which,  though 
compared  to  purulent  matter,  was  firm  and  coloured. 

Jo.  Ernest.  Grading,  apud  Ludwig  Adversaria  Medico-Practica,  Vol.  ii.  p.  ii.  p.  492. 
1771. — A woman  of  30,  of  delicate  constitution,  unmarried,  labouring  under  mania, 
ivith  paroxysms  of  great  violence  ; apoplectic  attack  followed  by  palsy  of  left  side  ; 
death  in  about  twenty  days  after.  In  the  right  hemisphere,  about  one  inch  below  the 
convoluted  surface,  an  ovoid  mass,  five  inches  long,  three  broad,  convex-shaped  h'ke  a 
lens,  one-fifth  of  an  inch  thick  at  middle,  resting  on  the  centrum  ovale  and  mesolobe. 


BRAIN. 


337 


consisting  internally  of  dark  red  (airo-rubens)  hard  granular  substance,  like  half-rotten 
sandy  pear,  enclosed  all  round  in  gray,  soft,  inodorous  puriform  matter,  (ramollisse- 
ment.) 

Mr  Henry  Earle,  in  Medico- Chirurgical  Transactions,  Vol.  ui.  p.  5.9.  1812.. — A boy, 
2 years  and  9 months  old.  Dilated  pupil  ; palsy  of  lower  extremities  and  sphincters, 
followed  by  convulsions  of  the  face,  and  palsy  of  the  upper  extremities  and  trunk  ; 
death  by  paralytic  asphyxia.  In  the  anterior  lobe  of  the  right  hemisphere  a large 
dusky  red  tumour,  rather  tough.  In  the  posterior  lobe  of  the  same  hemisphere,  and 
in  that  of  the  left,  a tumour  each.  In  the  cerebral  substance,  on  a level  with  the  me- 
solobe,  four  more  tumours  ; the  largest  the  size  of  an  orange,  the  smallest  not  less  than 
a chestnut.  They  were  very  firm,  of  a dusky'  red  colour,  and  with  streaks  of  white  in- 
terposed. 

Dr  Powell,  in  Medical  Transactions,  VoL  v.  Case  xi.  p.  211. — A man  of  30,  with 
excruciating  pain  of  the  head  more  or  less  constant,  followed  by  impciired  vision,  di- 
lated pupil,  and  at  length  an  apoplectic  attack,  which  in  two  days  terminated  life. 
From  the  inferior  part  of  the  anterior  lobe  of  the  left  hemisphere  projected  a firm 
mass,  of  the  size  of  a large  walnut,  and  when  cut  into  resembling  a large  absorbent 
gland.  It  was  surrounded  by'  softened  cerebral  substance,  which  was  of  a light  brown 
colour,  and  so  pulpy  as  to  give  the  sensation  of  a semifluid. 

y.  Tuhermlar  Deposition.  (^Tyroma.) — Under  the  head  of  tu- 
bercles and  scrofulous  growths  of  the  brain,  various  changes,  some 
not  very  similar,  have  been  described.  Though  the  terms  tubercle 
and  scrofula  have  been  perhaps  applied  too  vaguely,  these  differ- 
ences, however,  if  well  examined,  will  be  found  to  consist  more  in 
the  external  form  in  which  the  tubercular  matter  is  deposited,  than 
in  any  essential  change  in  its  intimate  characters.  The  term  tit- 
bercular  deposition,  therefore,  I adopt  for  the  purpose  of  designating 
matter  of  a white  or  pale-yellow  colour,  firm,  like  soft  cheese,  but 
less  tough,  sometimes  granular  and  friable,  and  consisting  chiefly 
of  a large  proportion  of  albuminous  matter.  The  substance  thus 
defined  may  be  deposited  in  various  forms.  In  the  brain  these 
seem  referable  chiefly  to  two ; — 1.  one,  two,  or  more  homogeneous 
individual  masses  of  considerable  size ; and  2.  several,  sometimes 
many,  minute  spherical  or  spheroidal  bodies  separate  from  each 
other. 

a.  One  or  two  homogeneous  masses  of  considerable  size.  Man- 
getus  is  among  the  first  who  notices  near  the  corpora  quadrigemina 
a body  like  a sebaceous  gland,  hard  and  friable,  which  there  is  rea- 
son to  believe  was  one  solitary  tubercular  mass.  The  two  similar 
which  he  found  in  the  same  brain  between  the  convolutions,  if  not 
belonging  to  the  membranes,  were  examples  of  the  same  growth  in 
the  convoluted  substance. 

I have  already  mentioned  under  another  head  the  case  of  Huber, 
which  is  probably  an  example  of  the  same  nature.  The  second 
one  of  Merat,  if  really  tubercular,  is  also  an  instance  of  this  form 

Y 


338 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


of  the  tubercular  deposit.  Many  others  are  recorded  by  different 
authors.  Thus  Rochoux  gives  an  instance  of  a tubercular  tumour 
in  the  cerebellum,  in  all  respects  similar  to  those  of  the  lungs.* 
Dr  Powell’s  seventh  case  is  an  instance  of  large  tubercular  masses 
in  the  white  matter  of  the  right  hemisphere.f  To  the  same  head 
also  belong  the  cheese -like  tumour  described  by  Sir  Gilbert  Blane;J 
the  white  tubercle  represented  by  Baillie,  (Plate  VII.  Fascic.  10;) 
and  the  instance  given  by  Coindet  in  the  annular  protuberance  ;§ 
the  instance  of  an  albuminous  mass  as  large  as  an  egg  in  the  ante- 
rior lobe  of  the  left  hemisphere  by  Bouillaud ; 1|  that  recorded  by 
the  same  author  as  a steatoraatous  tumour  in  the  left  hemisphere, 
containing  an  opaque  homogeneous  substance  like  white  paste  or 
thick  starch,  {Vempois  blanc,  p.  195  ;)  the  76th,  77th,  and  78th 
cases  of  Dr  Abercrombie  ; perhaps  that  of  Dr  Chambers  ;1T  a very 
good  instance  recorded  by  M.  Piedagnel  ;**  another  by  M.  Berard 
in  the  anterior  lobes,f|  and  perhaps  those  given  by  Dr  Hooper 
(Plate  XI.  Fig.  1.) 

The  physical  characters  of  this  form  of  tubercular  deposit  are 
tolerably  uniform.  Varying  in  number  from  one  or  two  to  four, 
five,  or  six,  and  in  size  from  that  of  a pea  to  a walnut,  they  consist 
of  opaque  white  matter,  with  a tint  of  pale-yellow,  of  the  consist- 
ence of  soft  cheese,  sometimes  granular,  but  always  without  vessel 
or  trace  of  organic  structure.  It  is  chiefly  albuminous  and  friable. 
In  general  they  are  surrounded  by  a vascular  cyst  of  variable  thick- 
ness. Of  the  manner  of  their  formation  little  is  known.  Several 
of  the  cases  of  Dr  Abercrombie  would  lead  to  the  idea,  that  the 
white  albuminous  matter  of  the  tubercle  is  deposited  in  a fluid  or 
semifluid  shape,  which  afterwards  undergoes  slow  coagulation.|| 
M.  Bouillaud  adduces  various  facts  and  arguments  to  show  that 
they  are  the  result  or  product  of  an  inflammatory  process ; and,  if 
the  idea  attached  to  this  term  be  sufficiently  comprehensive,  the 
opinion  may  not  be  remote  from  the  truth.  The  tendency  of  this 
process  is  to  produce  albuminous  secretions  or  depositions  in  va- 

• Recherches  sur  I’Apoplexie,  Obs.  xxxix.  p.  151. 

•b  Transactions  of  the  College  of  Physicians,  Vol.  v.  p.  222. 

J Transactions  of  a Society,  Vol.  ii. 

§ Memoire  sur  I’Hydrencephale,  p.  106  and  107. 

II  Traite  Clinique  et  Pathologique,  p.  161. 

^ Medical  and  Physical  Journal,  Vol.  Ivi.  New  Series,  Vol.  i.  1826,  p.  5. 

**  Journal  de  Physiologie,  Tome  iii.  p.  247. 

•ft  lb.  Tome  v.  p.  17. 

Pathological  and  Practical  Researches,  &c.  Cases  83,  84,  and  85,  in  which  the 
cysts  contained  soft  or  semifluid  albuminous  matter,  coagulable  by  heat.  Pp.  176-181. 

3 


BRAIN. 


339 


rious  forms  ; and  it  is  not  improbable,  that,  under  certain  circum- 
stances, it  may  be  so  modified  as  to  cause  the  deposition  of  this  sub- 
stance in  an  indivisible  mass,  in  a limited  situation,  and  from  a 
proper  cyst.*  Often,  however,  the  formation  of  these  bodies  is  the 
result  of  derangement  in  the  process  of  nutrition. 

Whatever  be  the  origin  of  these  bodies,  it  is  understood,  that, 
sooner  or  later,  they  undergo  a change  in  their  interior,  which 
sometimes  at  the  centre,  sometimes  in  several  points,  simultaneous- 
ly begins  to  soften  and  become  fluid.  It  is  at  least  known,  that 
such  bodies  are  found  to  have  fluid  or  semifluid  contents,  consist- 
ing chiefly  of  serous  liquor  with  albuminous  flakes  or  curd-like 
masses  in  it.  Of  this  description  are  the  tumour  of  the  protube- 
rance represented  by  Dr  Yelloly  as  in  a state  of  imperfect  suppu- 
ration ;f  the  cerebral  vomiccz  described  by  Coindet  as  similar  to 
tumours  of  meliceris ; the  seventy-fifth  case  of  Dr  Abercrombie ; 
that  in  the  protuberance  given  by  Dr  Kellie,  (Monro,  p.  178,)  and 
by  Dr  Moncrieff  in  the  same  work,  (pp.  50 — 53.)  When  the  sof- 
tening or  liquefying  process  is  complete,  the  tubercular  mass  as- 
sumes the  form  of  an  encysted  abscess.  Of  such  abscesses,  it  may 
indeed  become  a question  whether  the  fluid  or  the  solid  state  is  the 
incipient  one.  The  principal  facts  in  favour  of  the  latter  idea  are, 
the  circumstances  of  the  fluid  being  found  in  the  centre  while  the 
circumference  is  solid,  and  the  larger  bodies  being  found  soft 
while  the  small  are  Arm.  According  to  this,  wliich  is  the  general 
opinion  at  present,  in  the  incipient  stage  the  tubercle  is  said  to  be 
crude,  in  the  more  advanced  to  be  softened  or  dissolved. 

b.  The  second  form  in  which  tubercular  deposition  takes  place  is 
when  it  is  found  in  numerous  minute  spherical  or  spheroidal  bodies, 
disseminated  through  the  substance  of  the  brain.  Of  this  the  best 
examples  with  which  I am  acquainted  are  recorded  by  Reil  andM. 
Chomel.  In  tbe  case  given  by  Professor  Reil  more  than  200  ob- 
long spherical  bodies  were  found  in  the  gray  matter  of  the  brain 
and  cerebellum.  They  were  a little  firmer  than  the  brain  itself; 
mostly  of  a pale  yellow  ; some  few  of  a very  pale  blue  colour ; of 
the  size  of  a leutile  or  a pea ; and  when  divided,  showed  internally 
an  adipose-like  substance,  resembling  in  colour  and  consistence 
boiled  or  beaten  potatoes.  From  some,  which  were  marked  in  the 
centre  with  a dark  point,  and  seemed  to  be  covered  by  a thin  cyst, 
the  slightest  incision  discharged  a matter  like  vermicelli.  These 

* Traite  Clinique  et  Pathologique,  p.  181, 

t Medico-Chinirgical  Transactions,  Vol.  i,  p.  182. 


340 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


bodies  were  confined  to  the  gray  or  external  matter,  none  being 
found  in  the  white  cerebral  substance.*  Not  dissimilar  were  the 
bodies  found  by  M.  Chomel  in  the  brain  of  a woman  of  30,  who, 
with  obstinate  vomiting  and  epigastric  pain,  had  headach  at  first 
slight  and  confined  to  the  hind  head,  latterly  extending  to  the 
frontal  region,  when  it  was  constant  and  severe.  Though  the  in- 
tellectual powers  are  stated  to  have  been  unimpaired  to  the  last, 
death  was  preceded  by  sudden  aggravation  of  her  sufferings  and 
loss  of  consciousness.  In  the  brain  were  found  about  thirty  or 
forty  small  round  bodies,  resembling  the  human  crystalline  lens  in 
colour,  size,  and  consistence.  In  the  cerebellum  wei’e  two  similar, 
and  in  the  spinal  chord,  opposite  the  last  dorsal  vertebra,  one.  In 
several  parts  of  the  organ  also  were  minute  abscesses,  supposed  to 
be  produced  by  the  softening  of  similar  tubercles.f 

The  two  cases  now  noticed  are  considered  as  of  a strumous  nature 
by  the  authors  under  whose  observation  they  fell.  It  is  unfortu- 
nate that  they  have  given  almost  no  information  on  the  physical 
and  chemical  qualities  of  the  matter  thus  deposited  in  the  substance 
of  the  brain.  Though  its  nature  is  thus  left  undetermined,  I have 
ventured  to  I'efer  them  to  the  present  head,  because,  they  seem  to 
be  deposits  of  albuminous  matter  slightly  modified,  and  because 
they  doubtless  present  some  alliance  with  certain  of  the  forms  of 
tubercular  deposition  in  other  textures. 

F rom  the  researches  of  Dr  H.  Green , it  results  that  Tyroma  of 
the  brain  is  a disease  principally  of  early  life.  Among  30  cases  in- 
spected, all  were  between  the  ages  of  1 9 months  and  1 2 years ; and 
13  cases  occurred  between  the  ages  of  two  and  four  years  inclusive. 
As  to  sex,  14  cases  took  place  in  boys  and  16  in  girls.  It  is  a chro- 
nic disease,  and  causes  few  symptoms  until  it  has  encroached  much 
on  the  cerebral  substance.  J 

h.  The  Gelatinifurm  tumour.  ( Colloides. ) To  this  head  I refer 
a peculiar  sort  of  new  growth  which  1 have  seen  extending  over  the 
base  of  the  brain  from  the  optic  chiasma  backwards  to  part  of  the 
protuberance,  and  on  each  side  over  the  hemispheres.  The  body  was 
soft  and  jelly-like,  not  dissimilar  to  white  currant  jelly  or  thin  glue, 
tremulous,  and  easily  lacerable.  It  varied  in  thickness,  being  in  some 

* J.  C.  Reil,  Memorabilia  Clin.  Vol.  ii.  Fasc.  i.  No.  2.  1792. 

f Nouveau  Journal  de  Med.  Mars  1818,  p.  191-1 96.  A similar  is  given  in  the  sup- 
plement to  Dr  Abercrombie’s  work,  fiom  Prof.  Nasse,  p.  431.  The  case  of  Dr  Hawkins, 
(Aled.  and  Phys.  Journal,  Vol.  Ivi.  p.  8,)  may  probably  be  of  the  same  description. 

+ Observations  on  Tubercle  of  the  Brain  in  Children.  By  P.  II.  Green,  M.  D.,  Me- 
dico-Chinirgical  Transactions,  Vol.  XXV.  p.  192.  London,  1842. 

4 


BRAIN. 


341 


parts  as  thick  as  half  an  inch,  in  others  not  more  than  the  thickness  of 
two  crown  pieces  or  even  one.  Its  outline  was  irregular.  It  had 
produced  softening  of  the  hrain  on  the  part  where  it  pressed,  and 
the  base  of  the  cranium  on  which  it  rested  was  absorbed,  rough,  and 
carious.  The  dura  mater  corresponding  was  thin,  and  detached  from 
the  inner  table.  I do  not  think  that  this  substance,  which  was  void 
of  organization,  resembled  any  other  sort  of  tumour  which  I have 
seen  either  in  the  brain  or  elsewhere.  It  was  too  soft  and  too  la- 
cerable  to  be  compared  to  the  colloid  tumour.  It  was  contained 
within  a thin  arachnoid  membrane,  different,  as  it  appeared  to  me, 
from  the  arachnoid  membrane  of  the  brain. 

The  individual  in  whose  brain  this  production  took  place  had 
been  long  in  state  of  infirm  health  ; two  years  at  least.  The  first 
symptoms  were  epileptic  seizures ; then  loss  of  memory  of  that 
kind,  that  with  every  wish  and  effort  to  recall  either  a name  or  ob- 
ject, or  an  event,  he  was  quite  unable  to  do  so.  Latterly  the  fits 
became  more  frequent ; the  memory  more  thoroughly  impaired ; 
and  for  some  time  before  death  he  became  blind  and  paralytic. 
Death  was  preceded  by  great  debility  and  slight  stupor.  But  the 
epileptic  attacks  had  ceased  to  recur.  This  person’s  intellect  was 
originally  good  ; his  memory  was  powerful ; and  his  disposition  was 
mild,  gentle,  and  amiable.  On  these  mental  qualities,  excepting 
the  memory,  his  disease  seemed  to  make  no  impression.  I was  as- 
sured, that  a day  or  two  before  his  death  his  intellect  was  clear ; 
and  it  was  merely  the  remembrance  of  past  transactions  in  which 
he  was  confused.  He  could  by  no  means  be  said  to  be  insane  or 
even  fatuous. 

i.  Adipose  tumour,  lardaceous  degeneration.  {Keroma.')  Peter 
Borelli  is  the  first  who  notices  the  existence  of  much  fat-like  matter 
in  the  brain  of  an  epileptic  subject.  The  adipose  tumour  describ- 
ed by  the  Wenzels  seems  to  be  the  same  with  that  which  was  pre- 
viously mentioned  by  Merat,  and  winch  has  since  been  noticed  un- 
der the  name  of  lardaceous  degeneration  by  M.  Hebreart  formerly 
of  the  Bicetre.  The  first  author  describes,  under  the  name  of  tu- 
bercle behind  the  upper  part  of  the  medulla  oblongata,  a fatty,  red- 
dish, or  rose-coloured  body,  the  size  of  a nut,  consisting  internally 
of  homogeneous  substance  traversed  by  minute  red  lines,  probably 
blood-vessels.  It  was  contained  in  a fine  thin  envelope.  A similar 
one,  though  somewhat  less,  was  found  in  the  middle  of  the  left  ce- 
rebellic  hemisphere.  By  the  Austrian  anatomists  it  is  represented 
as  externally  smooth,  and  of  a yellow  colour,  and  internally,  when 


342 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


divided,  as  consisting  of  adipose  ash-coloured  solid  substance,  tend- 
ing in  some  parts  to  bony.*  Among  the  many  brains  which  these 
anatomists  examined  two  only  presented  this  change  of  structure. 
Though  found  near  the  exterior  or  convoluted  surface,  they  pene- 
trated pretty  deep  into  the  substance  of  the  organ. 

According  to  the  cases  given  by  M.  Hebreart  this  change  may 
occur  either  under  the  shape  of  a conversion  or  degeneration  of  the 
cerebral  substance  into  matter  of  a yellowish  colour  and  lardaceous 
consistence,  or  in  the  formation  of  a distinct  tumour  in  the  sub- 
stance of  the  organ.  Though  from  his  account  it  appears  to  he  by 
no  means  so  rare  as  might  be  expected  from  the  observations  of  the 
Austrian  anatomists,  he  gives  only  two  cases  of  its  occurrence  in 
the  brain,  and  two  in  the  cerebellum.  In  the  first  of  the  former, 
a distinct  tumour,  consisting  of  matter  of  a yellow-colour  and  lard- 
like consistence,  the  size  of  a nut,  in  the  anterior  part  of  the  an- 
terior lobe  of  the  right  hemisphei’e,  gave  rise  to  idiocy.  In  the  se- 
cond, a square  inch  of  the  posterior  lobe  of  the  left  hemisphere  was 
converted  into  a yellowish  pulpy  substance,  which  was  separated 
from  the  contiguous  sound  brain  by  hardened  cerebral  matter. 
This  in  a man  of  40  caused  epileptic  paroxysms  onee  or  twice  a 
month,  terminating  in  asphyxia,  which  at  length  proved  fatal.  In 
the  first  of  the  cerebellic  cases,  in  a young  man,  who  had  been 
idiotic  for  six  years,  the  cerebral  substance  forming  the  walls  of 
the  fourth  ventricle  had,  for  the  depth  of  more  than  one  line,  been 
converted  into  yellowish  lardaceous  matter.  In  the  second,  that 
of  an  incurable  maniac,  a space  six  lines  in  diameter  of  the  lower 
part  of  the  right  hemisphere  of  the  cerebellum  had  become  hard, 
lardaceous,  and  of  a yellowish  colour,  not  only  in  the  gray  lamel- 
lated  matter,  but  penetrating  for  some  lines  into  the  white  sub- 
stance. In  this  change  the  membranes  also  participated. f A si- 
milar case  is  related  in  the  Bulletins  de  la  Faculte  de  Medecine, 
May  1816. 

I know  not  whether  to  these  cases  should  be  added  the  third, 

* “ Tumor  exterius  Isevis  erat,  colore  luteo,  (couleur  jaunatre,  of  M.  Hebreart,)”  &c. 
“ Persecantes  tumorem,  intrinsecus  inveniebamiis  quandam  adiposam,  (“  ime  dege- 
nerescence  de  consistence  lardacee”  of  M.  Hebreart,)  subcineream,  admodum  solidam, 
(“  substance  devenue  dure,  lardacee,  de  couleur  jaunatre”)  substantiam  quse  parvo 
quodam  loco  tactu  velut  ossea  erat.”  Josephus  et  Carolus  Wenzel  de  Penitiori  Struc- 
tura  Cerebri  Hominis  et  Brutorum.  Tubingse  apud  Cottam,  1812,  Fol.  p.  104  et  105. 

Observations  sur  quelques  maladies  du  cervelet,  du  cerveau,  et  de  leurs  mem- 
branes, recueillies  a I’hospice  de  Bicetre  ; par  M.  Hebreart,  Medecin  ordinaire  des 
Alienes,  &c.  Annuaire  Medico-Chirurgical,  &c.  Paris,  1819,  p.  579. 


BRAIN. 


343 


given  by  the  same  author.  In  this  a man  of  50,  who  became  ma- 
niacal, with  lucid  intervals,  however,  lost  judgment,  speech,  memory, 
and  finally  became  paralytic  and  idiotical.  These  symptoms  were 
found  to  depend  on  the  conversion  of  the  lower  surface  of  the  left 
cerebellic  hemisphere  into  a jelly-like  matter,  separated  from  the 
sound  part  of  the  organ  by  walls  of  hard  polished  cerebellic  sub- 
stance. It  is  possible  that  this  jelly-like  matter  may  have  been 
either  the  result  of  the  process  of  softening  in  a part  previously 
hard,  or  the  incipient  stage  of  what  was  afterwards  to  acquire  the 
lardaceous  consistence. 

Margaroid  and  Cholesterine  tumour.  (^Margaroides.)  Cru- 
veilhier  describes  and  illustrates  with  figures  a tumour  consisting 
of  white  glistening  globular  masses,  like  pearls ; and  indeed  the  tu- 
mour appears  to  consist  of  minute  or  middle-sized  pearls  aggre- 
gated together.  These  bodies  vary  in  magnitude,  from  the  size  of 
vetches  to  that  of  peas.  The  colour  was  that  of  dead  silver,  pearl, 
or  whitish-gray  wax.  The  tumours  thus  formed  varied  in  size, 
from  that  of  a nut  to  a walnut,  or  a small  pippin.  In  general  the 
tumours  had  greater  latitudinal  extent  than  thickness.  They  were 
irregularly  round ; but  seemed  in  some  instances  to  consist  of  two 
or  more  tumours  aggregated  together. 

These  bodies  were  situate  mostly  on  the  base  of  the  brain,  over 
the  protuberance,  or  that  and  the  limbs  of  the  brain,  or  the  lower 
surface  of  the  cerebellum. 

This  sort  of  tumour  is  formed  in  the  subarachnoid  cellular  tis- 
sue, that  is  between  the  arachnoid  membrane  and  the  pia  mater. 
As  it  increases  in  size,  however,  it  encroaches  on  the  base  of  the 
brain,  and  it  may,  as  in  one  case  given  by  Cruveilhier,  destroy  the 
floor  of  the  third  ventricle  and  the  contiguous  parts,  and  present 
itself  immediately  beneath  the  fornix. 

This  tumour  presents  no  trace  of  organic  structure.  It  is  a se- 
creted product  or  deposit  formed  within  the  cells  of  the  cellular 
tissue ; a sort  of  adipose  matter  having  the  consistence  of  marrow 
or  suet,  covered  by  a layer  of  more  coherent  matter  imitating  the 
brilliancy  of  silver  or  pearl. 

When  this  substance  was  examined  chemically,  it  was  found  to 
consist  almost  solely  of  cholesterine. 

Of  the  cases  given  by  Cruveilhier,  one  occurred  in  a young  wo- 
man of  18  years;  another  took  place  in  an  old  soldier  of  40  years.* 

The  effects  produced  by  tumours  of  this  kind  are  very  similar  to 
* Anatomie  Pathologique.  Deuxieme  Livraison.  PI.  VI. 


344 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


those  resulting  from  other  tumours  developed  in  the  substance  or 
on  the  surface  of  the  brain.  Hebetude  of  the  intellectual  faculties, 
loss  of  memory,  epileptic  seizures  frequently  recurring,  a fatuous 
and  vacant  expression  of  countenance,  sometimes  blindness  or 
squinting,  then  stupor  and  palsy,  and  finally  death,  are  the  ordinary 
consequences  of  the  presence  of  this  deposit. 

The  same  cholesterine  deposit  in  scales  is  occasionally  found  on 
the  spinal  chord. 

ri.  Cartilarjinous  induration  ; Scirrhus ; {Chondromad)  This  is 
probably  to  be  regarded  either  as  a variety  of  the  first  kind,  or  as 
intimately  connected  with  it.  Unhappily  the  term  scirrhus  has 
been  so  vaguely  applied  to  every  kind  of  tumour,  if  a little  hard, 
that  no  precise  idea  is  communicated  by  it.  In  the  brain  especially 
all  authors  have  comprehended,  under  this  general  appellation, 
every  change  of  texture  which  was  harder  than  that  of  the  surround- 
ing organ,  without  much  regard  to  the  anatomical  characters  of  the 
new  substance.  Hence  we  find  all  the  instances  already  adduced 
recorded  as  examples  of  scirrhus,  though  in  many  of  them  no  proof 
of  this  structure  is  given,  and  in  none  is  there  any  other  proof  than 
the  greater  consistence  of  the  part. 

Without  attempting  to  define  the  character  of  scirrhus  when  oc- 
curring in  the  brain,  I refer  to  the  present  head  those  instances  of 
morbid  structure  in  which,  with  hardness  approaching  to  that  of 
cartilage,  there  is  a fibrous  arrangement,  and  more  or  less  tendency 
to  cancerous  ulceration.  Even  with  this  limitation  it  may  be  doubt- 
ed whether  this  disease  occurs  primarily  in  the  cerebral  substance. 
Meanwhile,  however,  for  want  of  more  satisfactory  elements  in  the 
arrangement  of  the  organic  changes  incident  to  the  brain,  to  this 
head  may  be  referred  the  following  examples: — 

AI.  Jean  CniveCliier,  Essai  sur  I’Anatomie  Pathologique,  Tome  ii.  p.  80.  Paris, 
1816. — A woman  of  40  was  brought  to  the  Hotel- Dieu  in  a state  of  idiocy,  in  which 
slie  was  stated  to  have  been  for  six  months  after  severe  mental  distress.  She  lived  a 
month  without  much  sign  of  intellect,  became  comatose  and  died.  In  the  right  he- 
misphere, beneath  the  mesolobe,  corresponding  to  the  striated  body  on  the  outside,  and 
projecting  into  both  ventricles,  was  found  a hard  tumour  of  a triangular  shape,  the 
posterior  angle  elongated,  the  right  anterior  angle  advancing  to  the  anterior  extremity 
of  the  right  lobe.  It  consisted  of  two  sorts  of  structure; — one  in  tlie  centre,  as  large  as 
a pigeon’s  egg,  had  the  consistence  of  fibro-cartilage,  and  resembled  fibrous  substances 
proceeding  to  the  cartilaginous  state;  the  other  exterior,  grayish,  was  confounded  with 
the  cerebral  substance  from  which  it  appeared  to  be  formed. 

L.  N.  Rostan,  Recherches  sur  une  Maladie  encore  pen  connue.  Paris,  1820.  P.  84. 
Observ.  20ieme.  1820. — A woman  of  G2  had  during  the  course  of  life  been  deranged 
several  times,  during  which  she  committed  extravagant  acts,  though  rare  and  of  short 
duration.  She  had  now  constant  headach,  with  occasional  raving,  giddiness,  and  vo- 


BRAIN. 


345 


miting,  followed  by  palsy  of  the  right  side,  and  complete  derangement.  In  a few  days 
more  she  became  comatose,  and,  with  complete  right  hemiplegia  and  stertorous  respi- 
ration, she  expired.  In  the  upper  middle  of  the  left  hemisphere,  which  was  softened 
all  round,  a little  beneath  the  convoluted  substance,  was  a small  yellowish  granular 
nut.  Anteriorly  in  the  striated  body  was  a cancerous  tumour  as  large  as  a nut,  com- 
pressing the  ventricle.  In  the  right  hemisphere,  which  was  sound  and  consistent  in  its 
anterior  three-fourths,  but  injected  towards  the  posterior- inferior  region,  was  a cancer- 
ous tumour  as  large  as  a small  nut,  with  pulpy  destruction  of  the  surrounding  sub- 
stance. 

This  account  is  deficient  in  failing  to  state  the  physical  characters 
of  the  several  tumours.  A record  more  instructive  is  found  in  the 
following : — 

M.  Andral  Fils,  Cancer  du  Cerveau,  from  La  Charite,  in  the  wards  of  M.  Lerminier, 
Journal  de  Physiologie,  Tome  ii.  p.  105,  1822. — A man  of  58  felt  fifteen  years  before 
acute  pain  of  the  right  temple,  radiating  in  the  right  side  of  the  head  and  face,  and 
lasting  for  six  weeks.  Diu'ing  subsequent  years  it  returned  at  irregular  intervals,  and 
continued  for  periods  of  various  duration  till  two  months  pre^'ious  to  admission,  when 
it  became  so  intense,  as  to  oblige  the  patient  to  give  up  his  usual  employments.  With- 
out affection  of  sensation,  intellect,  or  motion,  he  suffered  severe  tearing  pain  in  the 
whole  right  side  of  the  head,  and  slight  convulsive  motions  of  the  face,  followed  after 
eight  days  by  palsy  of  the  lower  limbs,  and  soon  after  by  coma,  which  continued  in  a 
greater  or  less  degree  for  a few  days,  when  he  died.  In  the  centre  of  the  right  hemi- 
sphere, outside  of  the  optic  thalamus  and  corpus  striatum,  the  space  of  four  finger- 
breadths  long,  and  two  or  three  wide,  was  a reddish-gray,  knotty,  rough,  unequal  sur- 
face, which  when  cut  resisted  like  the  scirrhous  masses  of  the  stomach  or  liver.  In 
the  resisting  points  was  a substance  of  areolar  texture,  bluish-white  colour,  semitran- 
sparent, very  hard,  presenting  here  and  there  minute  cavities  containing  a fluid  like 
apple-jelly  ; (scirrhus  proceeding  from  the  crude  to  the  softening  stage).  In  other 
points  was  a firm  texture  of  dirty  white  colour,  traversed  by  reddish  lines  crossing  in 
various  directions  (supposed  to  be  encephaloid  texture  in  the  crude  stage.)  In  other- 
points  was  seen  a reddish-purple,  which  appears  to  have  been  simply  softened  brain. 

Bouillaud,  Traite  Clinique  et  Physiologique  de  TEnceqihalite.  1825. — A lady  of  77, 
with  conr-ulsive  motions  of  the  left  arm,  followed  by  palsy  of  that  and  of  the  left  leg, 
impah-ed  speech,  complete  hemiplegia,  and  death  by  exhaustion,  without  loss  of  con- 
sciousness, a firm,  yellonfish,  lardaceous,  bulky,  many-lobed  mass,  occupying  the  greater 
part  of  the  posterior  lobe,  almost  the  whole  of  the  middle  lobe,  and  part  of  the  anterior 
lobe  of  the  right  hemisphere.  Contiguous  to  the  optic  thalamus,  which  was  entirely 
softened,  a lobule  penetrated  below  the  striated  body,  and  reached  the  exterior  of  the 
middle  lobe,  where  it  was  connected  with  the  membranes  and  the  bone.  Softening  all 
round.* 

Ibid. — A man  of  66.  Right  hemiplegy  twice,  followed  by  raving,  unintelligible 
speech,  insensibility,  coma,  and  death.  In  the  central  and  posterior  part  of  the  left 
hemisphere  a hard  irregular  mass,  internally  of  a saffron-yellow  colour  in  some  parts 
of  a rust-yellow  in  others,  jaspered,  marked  by  numerous  small  white  bodies  varying 
from  the  size  of  a lentile  and  a pea  to  that  of  a filbert,  furrowed  in  various  directions  by 
minute  filaments.  The  hardest  of  these  bodies  M.  Bouillaud  regards  as  scirrhous  mat- 
ter in  the  crude  stage.  Others  resembling  a white  concentrated  glue,  he  thinks,  might 

* This  case  is  stated  to  be  already  published  in  the  work  of  M.  Rostan.  This,  however,  appears  to 
be  a mistake.  The  only  example  of  cancer  in  the  brain  recorded  in  that  work  is  the  case  above  men- 
tioned of  Marie  Gerard.  With  this  it  evidently  does  not  correspond,  either  in  age  or  in  other 
circumstances.  A case  of  tumour  called  cancerous  is  also  given  in  the  " Observations'’  of  M.  Lenni- 
nier. — Annuaire  Medico-Chirurg.  p.  225. 


346 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


be  the  colloid  or  glue-like  cancer  of  M.  Laennec.  While  the  gi’eater  part  of  thia  body 
was  hard,  its  centre  was  reduced  to  a yellow  diffluent  pulp. 

Mr  R.  Wade,  Medical  and  Physical  Journal. — In  the  upper  part  of  the  left  lobe 
(hemisphere)  of  the  brain,  a hard  body  of  the  size  of  a small  hen’s  egg,  like  medullary 
sarcoma,  but  as  firm  as  scirrhus  of  the  female  breast.  The  greatest  part  consisted  of 
yellow-white  striae,  as  hard  as  cartilage,  the  remainder  dark-gray  and  less  firm,  not  very 
distinguishable  after  maceration.  Pulpy  destruction  around. 

Under  his  fifth  head,  Dr  Monro  has  shortly  noticed  seven  speci- 
mens of  this  change  of  structure  preserved  in  the  University 
Museum.  Its  hardness,  irregular  surface,  and  cartilaginous  struc- 
ture, with  a resemblance  to  a section  of  the  kidney,  are  the  circum- 
stances principally  remarked. 

From  the  above  acconnts,  which  I consider  to  be  the  most  au- 
thentic on  record,  a general  idea  of  the  anatomical  characters  of 
what  is  meant  by  scirrhus  of  the  brain  {chomdroma)  may  be  ob- 
tained. A mass  generally  of  irregular  shape,  distinguished  from 
the  surrounding  cerebral  substance  by  its  firmness,  sometimes  a 
lobnlated  structure,  by  its  interior  substance  consisting  of  a pro- 
portion more  or  less  considerable  of  yellowish  matter  as  hard  as 
cartilage,  arranged  sometimes  in  streaks  or  bands,  in  other  cases 
in  round  nodules,  constitutes  the  principal  characters  of  this  mor- 
bid growth  in  its  crude  or  early  stage.  At  a more  advanced  pe- 
riod cavities  begin  to  be  formed,  in  which  is  contained  a fluid  or 
semifluid  matter  sometimes  jelly-like,  at  other  times  thinner,  and 
occasionally  tinged  with  blood.  Before  this  process  of  softening 
has  advanced  far  death  takes  place  in  general  by  suspension  of  the 
functions  of  the  organ. 

The  cartilaginous  tumour  may  be  deposited  in  a tubercular  form, 
and  perhaps  consisting  partly  of  tubercular  or  albuminous  matter. 
Of  this  a good  instance  is  given  by  Bayle  in  his  Treatise  on  Pul- 
monary Consumption.  A printer  of  58,  with  complete  paraplegy, 
and  obliteration  of  the  intellect  almost  to  idiocy,  followed  by  weak- 
ness of  the  arms  and  sudden  loss  of  speech,  died  with  lethargy  and 
paralytic  dyspnoea.  In  the  anterior  part  of  the  right  hemisphere 
was  a tubercular  and  cancerous  mass  the  size  of  a turkey’s  egg, 
nearly  spherical,  and  of  considerable  consistence  and  specific  gra- 
vity. With  a reddish-gray  surface  irregularly  knobbed,  traversed 
by  blood-vessels,  it  consisted  internally  of  a canary-yellow,  thick, 
granular,  pasty  matter,  void  of  vessel  or  trace  of  organization,  re- 
sembling serofulous  tubercles  beginning  to  soften,  with  this  diffe- 
rence, that  in  some  points  it  was  humid  and  infiltered  with  serous 


BRAIN. 


347 


fluid.  This  was  the  case  in  the  walls  of  an  anfractuous  irregular 
cavity  without  membrane,  and  containing  two  spoonfuls  of  clear 
yellowish  fluid.  The  tubercular  matter  formed  the  centre  and  the 
three  upper  fourths  of  the  tumour.  The  rest  was  what  is  described 
as  cancerous, — a firm  grayish- white  shining  tissue,  traversed  in  all 
directions  by  blood-vessels,  and  presenting  even  a minute  bloody 
effusion.  Though  the  tumour  was  without  cyst,  its  surface  was 
covered  by  a celluloso-vascular  tissue,  which  sent  numerous  irre- 
gular productions  into  the  substance.  It  was  surrounded  by  a layer 
of  cerebral  matter,  reduced  as  usual  to  the  consistence  of  thick 
cream.* 

6.  Calcareous  or  Bony  deposits,  and  Concretions. — This  morbid 
deposition  is  by  no  means  so  common  in  the  brain  as  in  its  mem- 
branes ; and  a large  proportion  of  the  cases  termed  ossification  or 
petrification  of  the  brain  are  doubtless  examples  of  ossific  tumours 
originating  in  the  membranes.  It  appears,  nevertheless,  that  some 
instances  have  occurred  to  different  observers.  Kerkringius  men- 
tions as  a cause  of  fatuity,  a concretion  weighing  thirteen  grains  in 
the  right  ventricle.!  Kentmann-  notices  an  ash-coloured  one,  the 
size  and  shape  of  a mulberry  Deidier  found  the  left  corpus  stria- 
tum osseous  ;§  and  Tyson  mentions  the  case  of  a man  who  died  of  the 
efiects  of  a blow  on  the  head,  in  whom  one  of  the  inferior  corpora 
quadrigemina  was  as  large  as  a nutmeg,  and  contained  a chalk  mass 
like  a cherry-stone,  with  pulpy  destruction  of  the  organ.  ||  Blegny  saw 
a stone  as  large  as  a bean  at  the  union  of  the  optic  nerves  in  the 
brain  of  a lady,  who,  after  violent  pains  of  the  head  with  fever,  be- 
came blind,  and  died.f  In  the  brain  of  a man  who  had  suffered 
long  from  acute  pain  of  the  hind  head,  notwithstanding  the  use  of 
blisters,  setons,  &c.  M.  Boyer  found  a hard  plaster-like  concretion  as 
large  as  a filbert.**  In  the  hrain  of  a boy  of  16,  an  idiot  from  birth, 
Sir  E.  Home  found  the  protuberance,  cerebellic  peduncles,  and 
part  of  the  cerebellum,  containing  so  much  earthy  matter  as  to  be 
with  difficulty  cut  by  the  knife.tt  Professor  Nasse  found  in  the  left 

* Recherches  sur  la  Phthisie  Pulmonaire,  &c.  Par  G.  G.  Bayle.  A Paris  1810 
P.  305. 

t Observat.  Anatom.  35. 

^ De  Calciibs  LibeUns. 

§ Des  Tnmeurs,  p.  351. 

II  Philosopbical  Transactions,  No.  228. 

^ Zodiacus  Gallicus,  Obs.  xiv.  p.  81. 

**  Cruveilhier,  Essai  sur  PAnatomie  Pathologique,  T.  ii.  p.  84. 

-t”t-  Phil.  Trans.  1814. 


348 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


lobe  of  the  cerebellum  a body  one  inch  long  and  ten  lines  broad, 
composed  of  alternate  layers  of  chalky  matter,  fluid  albumen  and 
solid  albumen.*  Lastly,  Andral  in  a phthisical  subject  found,  in 
the  substance  of  the  left  hemisphere,  near  its  upper  anterior  extre- 
mity, a granulation  the  size  of  a large  pea,  with  the  consistence  of 
the  calcai’eous  concretions  of  the  lung.f 

In  such  cases  a minute  portion  of  brain  appears  not  to  be  con- 
verted into  bone,  but  to  be  infiltrated  with  chalky  matter,  void  of 
animal  substance  so  far  as  can  be  discovered.  Of  these  earthy  de- 
posits no  analysis  has  yet  been  made.  It  is,  however,  not  impro- 
bable that  they  consist  chiefly  of  lime,  united  either  with  carbonic 
or  phosphoric  acid,  or  both.  Dr  Hooper  has  delineated  in  his 
twelfth  engraving  a bony  tumour,  or  what  he  names  a tubercle, 
which  is  said  to  consist  of  the  same  materials  as  healthy  bone,  with 
a little  more  animal  matter.  It  is  not  stated  whether  this  was 
found  in  the  cerebral  substance  or  connected  with  the  membranes. 
From  its  appearance,  however,  and  the  fact  now  stated  of  its  che- 
mical character,  I think  it  next  to  certain  that  it  was  of  the  latter 
description.  Upon  the  whole,  it  may  be  inferred  that  the  sub- 
stances denominated  concretions  of  the  brain  consist  of  infiltrations 
or  depositions  of  calcareous  matter  in  the  substance  of  the  organ. 

To  this  head  may  be  referred  the  concretions  found  in  the  cona- 
rium  or  pineal  gland.  In  this  body  small  sabulous  or  calcareous 
particles  have  been  very  often  found ; and  it  was  long  supposed, 
partly  in  consequence  of  the  hypothetical  opinions  of  Descartes, 
that  this  change  could  not  fail  to  affect  materially  the  functions  of 
the  entire  organ.  For  correct  information  on  this  point,  we  are 
indebted  to  Soemmering,  who  showed  by  the  collation  of  numerous 
cases,  that  scarcely  any  person  arrived  at  the  age  of  puberty, 
though  in  the  best  health  and  the  most  perfect  enjoyment  of  his 
faculties,  could  assure  himself  that  his  conarium  did  not  contain 
calcareous  matter.  He  regards  it  as  part  of  the  natural  structure. 

Though  Soemmering  states  that  sabulous  deposition  is  found  in 
the  conarium  of  infants  as  well  as  adults,  he  nowhere  specifies  the 
exact  authority  for  this  fact ; and  the  youngest  subjects  on  which 
he  records  its  occurrence  v'ere  14  and  16.j;  The  Wenzels  assert 

■*  Abercrombie,  Pathological  and  Pract.  Researches,  p.  42(i. 

+ Journal  de  Physiologie,  Tome  ii.  p.  110. 

X S.  T.  Soemmering  de  Acervulo  Cerebri  Dissert.  Apud  Ludwig,  Scriptorum  Ncu- 
rolog.  nunc  Delect,  p 322,  329. 


BRAIN-. 


349 


that  they  have  seen  stony  particles  so  early  as  the  7th  year,  and  a 
substance  very  similar  a few  months  after  birth.*  I am  satisfied 
that  I have  seen  in  the  pineal  glands  of  young  children,  whose  ages 
I could  not  ascertain,  but  who  certainly  did  not  exceed  9 or  10, 
small  sabulous  particles  ; but  my  personal  observation  does  not  en- 
able me  to  say  how  far  the  statement  of  the  Austrian  anatomists 
as  to  earlier  periods  is  correct. 

The  couarium  itself  consists  chiefly  of  firm  reddish  gray  cerebral 
matter,  at  the  basis  or  posterior  end  of  which  are  two  whitish 
threads,  which  proceed  on  each  side  to  the  optic  thalamus,  and  form 
what  are  termed  the  peduncles  of  the  gland,  from  which  they  are 
separated  by  a small  linear  depression.  Behind  the  union  of  these 
peduncles,  covered  here  by  part  of  the  choroid  web,  is  placed  inva- 
riably an  irregular-shaped  mass,  varying  in  size  from  that  of  a 
small  pin-head  to  a grain  of  hemp-seed.  When  seized  by  the  for- 
ceps this  is  found  to  grate  like  sand  or  grains  of  stone ; and  when 
examined  it  actually  consists  of  minute  granules  aggregated  to- 
gether by  membranous  filaments  of  animal  matter.  This  irregu- 
lar-shaped sandy  mass  is  what  is  termed  by  Soemmering  acervulus 
conarii.  The  granules  in  the  centre  are  generally  larger  than 
those  at  the  surface  ; and  its  irregular  shape  depends  on  the  num- 
ber and  size  of  the  small  superficial  granules.  They  are  generally 
yellow  or  citron-coloured,  hard,  rough,  semitransparent,  and  dis- 
tinctly grating  on  a steel  instrument. 

Besides  the  situation  now  mentioned, — the  union  of  the  pedun- 
cles,— sandy  particles  are  occasionally  found  anterior  to  the  pe- 
duncles close  on  the  basis  of  the  gland,  or  disseminated  in  its  sub- 
stance. In  infants  before  the  7th  year,  it  is  never  found  in  the 
substance  of  the  conarium,  but  generally  in  the  plate  which  con- 
nects it  to  the  thalami.  The  most  ordinary  place  for  it  in  adults 
is  the  pit  between  the  conarium  and  its  peduncles ; and  in  aged 
subjects  it  may  be  found  in  all  the  three  situations.  It  has  been 
found  in  natives  of  every  European  nation  almost,  and  in  Africans. 

According  to  the  analysis  of  Muller  these  stones  contain  calca- 
reous earth  ; and  from  some  experiments  of  Miinch  it  appears  that 
the  lime  is  united  with  oxalic  acid. 

Whatever  be  the  quantity  of  this  deposition,  it  is  well  ascertained 
that  it  exercises  no  influence  on  the  cerebral  functions.  It  is  ne- 
vertheless difficult  to  imagine  it  to  be  a natural  or  healthy  product. 

* De  Penitiori  Stmctxira  Cerebri,  pp.  155 — 157. 


350 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


From  its  situation  I have  often  been  inclined  to  think  that  it  is  a 
secretion  from  the  vessels  of  the  choroid  web. 

Petrifaction,  or  osseous  induration  of  tbe  whole  brain,  has  not 
been  seen  in  tbe  human  subject.  Instances,  however,  of  this  in  the 
lower  animals  have  been  recorded  by  Duverney,  Simson,  Pitchell, 
and  Renauld. 

Encysted  Tumours. — Of  these  any  of  the  forms  may  probably 
be  found  in  the  brain.  Hitherto,  however,  those  actually  said  to 
occur  may  be  referred  to  one  or  other  of  the  following  heads. 

a.  Plydatoid  or  vesicular  tumours.  It  may  be  justly  doubted 
whether  the  genuine  animal  hydatid,  (^Cysticercus  cellulosus,  Ru- 
dolphi,)  has  ever  been  found  in  the  brain.  Though  stated  gene- 
rally by  Bremser,  he  mentions  no  authority  ;*  it  is  never  noticed 
by  Rudolphi  ;•]-  and  seems  to  be  denied  entirely  by  Blainville. 
None  of  the  social  hydatids  (^Coenuri  and  Echinococci')  were  found 
in  that  situation,  till  M.  C.  Rendtorff  discovered,  in  1811,  a cluster 
of  the  latter  sort  in  the  right  ventricle  of  a girl  of  8,  who,  after  re- 
maining hemiplegic  for  some  months,  died  lethargic.^; 

Notwithstanding  this,  instances  of  bodies  described  as  hydatids 
occurring  in  the  brain  have  been  mentioned  by  Scultetus,  Panaroli, 
Paw,  Borelli,  Lancisi,  Wepfer,  Home,  Rostan,  Headington,  and 
IMorrah.  In  the  case  of  Scultetus,  a cyst  as  large  as  a hen’s  egg, 
not  unlike  a hydatid,  was  found  in  the  left  hemisphere. § In  that 
of  Panaroli,  several  whitish  round  bladders,  containing  pituitous 
fluid  {hygroma  ?)  were  found  in  tbe  mesolobe.||  In  that  of  Paw,  a 
bladder  containing  half  a pound  of  limpid  fluid  was  seated  over  the 
commissure  of  the  optic  nerves.^  The  case  of  P.  Borelli  was  a 
cyst  containing  watery  fluid,  attached  to  the  nates  and  infundibu- 
lum.**' That  of  Lancisi  is  styled  a hydatid  as  large  as  a pigeon’s 
egg,  thin,  yellowish,  jelly-like  lymph,  in  the  posterior  part  of  the 
right  hemisphere.ft  The  case  of  Wepfer,  which  was  a cyst  as 
large  as  a hen’s  egg,  containing  a turbid  brownish  liquor,  appears 
to  belong  rather  to  the  head  of  hygroma.\\  Those  of  Home,§§  Ros- 

* Traite  Zoologique,  &c.  Paris,  1824,  P.  141,  chap.  ii. 

•f-  Entozoorum  Synopsis.  Mantissa,  Gen.  28,  p.  546. 

J De  Hydatidibus  pra;sertim  in  cerebro  repertis. 

§ Armamentarium,  Obs.  10  and  11. 

II  Pentecoste  I.  Obs.  17.  ^ Petri  Pawdi,  Observat.  2. 

**  P.  Borelli,  Obs.  Medico-Physicse. 

-]”t-  De  Mortibus  Subetaneis,  Lilj.  i.  cap.  xi.  13. 

HistoriiE  Apoplecticorum. 

§§  Phil.  Trans.  1814,  p,  483. 


BRAIN. 


351 


tan,* * * §  Headington,f  and  IMorrah,;};  though  more  recent,  are  not 
more  unequivocal,  since  their  authors  give  no  description  of  the 
physical  characters  by  which  their  claim  to  the  title  of  hydatids 
might  be  determined. 

Upon  the  whole,  though  the  occurrence  of  the  genuine  solitary 
animal  hydatid  in  the  brain  may  not  be  impossible,  it  is  not  clear 
that  any  of  the  cases  hitherto  recorded  belong  to  this  head.  They 
are  to  be  regarded  rather  as  serous  or  vesicular  cysts,  (Portal, 
Anat.  Med.  Tome  IV.  p.  72,)  or  examples  of  the  tumour  called 
(hygroma).  Of  this  kind  also  are  the  case  described  by  Forlani  of 
Sienna,  containing  glutinous  matter  like  white  of  egg,§  and  the 
globular  cysts  so  beautifully  represented  by  Dr  Hooper  in  his  four- 
teenth engraving.  The  cases  mentioned  by  Fischer,  Zeder,  and 
others,  belong  to  the  membranes. 

b.  Steatoms  are  mentioned  by  Drelincurtius,  Thomann,  Home, 
and  Bouillaud. 

c.  The  blood-cyst,  (hcBmatoma).  The  occurrence  of  this  in  the 
brain,  though  not  common,  has  been  observed.  Like  hccmatoma 
in  other  regions,  it  consists  of  a membranous  cyst,  sometimes  con- 
taining small  cysts,  the  inner  surface  of  which  is  composed  of  a 
vascular  tissue,  from  which  blood  or  bloody  fluid  exudes  by  exha- 
lation, forming  a mass  resembling  layers  of  coagulated  blood.  Of 
this  disease  the  most  distinct  example  is  given  by  Rochoux.  A 
man  of  65,  about  twenty  months  after  a violent  blow  on  the  head 
which  stunned  him,  began  to  feel  pain  and  weight  of  the  head,  with 
occasional  moments  of  forgetfulness.  These  symptoms  became 
more  severe  and  more  frequent,  were  followed  by  embarrassed 
speech,  palsy  of  the  left  side  of  the  face,  great  general  weakness, 
coma,  and  death.  In  the  anterior  and  external  part  of  the  left  he- 
misphere was  found  a firm  red-brown  tumour,  the  size  of  an  egg, 
round,  flattened,  filled  with  blood,  which  in  certain  places  appeared 
to  be  contained  as  in  the  spleen,  in  others  in  small  clots  of  a line 
diameter  of  an  areolar-cellular  tissue,  grayish,  dense,  and  analogous 
in  appearance  to  the  matter  of  tubercles.  Adhering  without  to 
the  dura  mater  of  the  arachnoid,  which  was  red  and  much  thick- 

* Recherches,  &c.  Chap.  x.  Acephalocystes,  p.  166. 

t Medical  and  Surgical  Joiunal,  Vol.  XV.  504. 

X Medico-Chinirgical  Transactions,  Vol.  II.  p.  262. 

§ Caspar  M.  Forlani,  Obs.  Med.  Pract.  Anat.  Senis,  1769. 


352 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


ened,  it  was  lodged  in  a depression  of  the  hemisphere.  The  con- 
tiguous cerebral  matter  was  in  the  state  of  yellow  ramollissement.* 

In  his  tenth  engraving  Dr  Hooper  gives  a good  delineation  of 
an  example  of  this  disease.  In  this  case  the  tumour,  which  was  of 
an  irregular  oblong  spheroidal  shape,  about  3-|  inches  long  and  2^ 
broad, ^arose  by  a broad  base  from  the  white  cerebral  substance  of 
the  left  hemisphere  near  the  ventricle,  but  not  communicating  with 
that  cavity.  Externally  it  was  of  a pink-red,  or  pale  carmine  co- 
lour, and  of  an  irregularly  lobulated  arrangement.  Though  soft 
to  the  touch,  it  was  elastic  and  cut  firm,  exposing  a vascular  mot- 
tled surface  of  a reddish-yellow  colour,  with  portions  of  blood-like 
structure  here  and  there.  Besides  the  jna  mater,  which  it  raised, 
it  was  covered  by  a delicate  and  very  vascular  membrane,  laminat- 
ed and  shaggy. 

A tumour  of  similar  characters  is  described  under  his  sixth  head 
by  Dr  Monro  Tertius,\  formerly  Professor  of  Anatomy.  In  a 
young  man  who  had  suffered  from  headach,  impaired  vision,  and 
nausea,  followed  by  epilepsy  terminating  fatally  in  a few  hours,  in 
the  middle  lobe  of  the  right  hemisphere  was  a body  the  size  of  an 
orange,  somewhat  soft,  but  elastic,  and  of  the  colour  and  consist- 
ence of  clotted  blood.  The  surrounding  brain  was  in  a state  of 
pulpy  destruction. 

These  two  last  cases  are  regarded  as  similar  to  the  tumour  named 
haematoid  fungus.  I am  not  prepared  to  prove  that  they  do  not 
belong  to  this  head ; but  their  general  resemblance  in  anatomical 
characters  to  that  described  by  Rochoux,  induces  me  to  refer  them 
to  the  head  of  Hcematoma. 

To  the  same  head  may  be  referred  that  described  by  Dr  George 
Gregory,!  who,  in  a man  labouring  under  headach,  irritable  sto- 
mach, and  epileptic  fits,  and  finally  destroyed  by  epilepsy,  found 
within  a cyst  in  the  anterior  cornu  of  the  left  ventricle,  before  the 
striated  nucleus,  a body  as  large  as  a nutmeg,  hard  and  fleshy,  la- 
minated interiorly  an  inch  thick  like  coagulated  blood,  with  a cavity 
in  the  centre. 

d.  Fungus  Hcematodes.  Encephaloid  or  Cerehriform  tumour. — 
This  morbid  growth  has  been  often  found  in  the  brain  either  ex- 
clusively or  in  common  with  other  textures.  Enclosed  almost  in- 

* J.  A.  Rochoux,  Recherches  sur  TApopIexie.  A Paris,  1814.  Obs.  38,  p.  149. 

t The  Morbid  Anatomy  of  the  Brain.  By  Alex.  Monro,  M.  D.  &c.  p.  56.  chap.  i. 

:[:  Medical  and  Physical  Journal,  Vol.  LIV.  p.  462. 


BRAIN. 


353 


variably  in  a cyst,  it  consists  of  soft,  compressible,  spongy  matter, 
of  the  consistence  of  foetal  brain,  and  not  dissimilar  in  colour  to 
gray  cerebral  matter,  with  a tinge  of  red,  a shining  aspect,  divided 
in  lobulated  masses,  which  move  on  each  other  when  slightly 
touched.  Though  found  chiefly  in  young  subjects,  it  may  occur  in 
the  brains  of  adults;  but  is  rarely  seen  in  the  aged.* 

e.  Melaiiosis.  The  melanotic  deposit  has  not  been  very  often  found 
in  the  brain.  Streaks  of  dark  matter  along  the  blood-vessels  were 
seen  by  Dr  Alison  and  Mr  Fawdington  and  Dr  Hooper  deline- 
ates melanotic  masses  of  small  size  in  the  substance  of  the  organ.J 
Of  these  several  changes  now 'enumerated,  the  effects,  in  general 
uniform,  may  be  said  to  vary  only  according,  Is^,  to  the  morbid 
changes  induced  in  the  contiguous  cerebral  substance ; 2d,  accord- 
ing to  the  extent  which  the  organic  change  occupies ; and  ^dly, 
according  to  its  relative  situation  in  the  organ. 

1.  All  the  tumours  above  enumerated,  independent  of  the  changes 
proper  to  their  own  structure,  agree  in  producing  certain  common 
changes  in  the  contiguous  cerebral  substance.  All  of  them  tend 
to  derange  the  capillary  circulation  of  the  brain  and  its  membranes. 
In  the  former  they  induce  not  only  a general  injection  of  the  cere- 
bral capillaries,  but  a local  action  in  the  immediate  confines  of  the 
tumour,  and  pulpy  destruction  of  the  cerebral  substance.  It  often 
happens  also  that  the  whole  organ  is,  in  consequence  of  the  capil- 
lary injection,  infiltrated  by  pale  or  bloody  serous  fluid.  In  the 
membranes  these  tumours  also  induce  injection,  terminating  in  in- 
filtration of  the  subarachnoid  tissue,  and  effusion  from  the  choroid 
web  into  the  ventricles.  The  effects  on  the  cerebral  functions  are 
then  precisely  similar  to  those  which  result  from  derangement  of 
the  capillary  circulation  taking  place  primarily.  If  local  and  in- 
termittent, that  is,  recurring  on  the  operation  of  certain  causes,  the 
irritation  from  the  tumour  and  its  disturbance  on  the  capillary  cir- 
culation induces  chronic  headach,  with  epileptic  attacks.  When  the 
vascular  orgasm  becomes  more  general  and  constant,  loss  of  memory, 
and  sometimes  of  judgment,  irregular  contractions  of  the  members, 
and  more  or  less  palsy,  are  the  consequences.  As  it  advances  to 
pulpy  destruction,  the  involuntary  contractions  of  the  muscles  are 
followed  by  palsy ; the  abolition  of  sensation,  recollection  and  in- 

* Observations  on  Fungus  Hematodes,  by  James  AVardrop.  Edinburgh,  1809.  To 
this  belongs  the  case  of  Dr  Latham,  in  Medical  and  Physical  Journal,  Vol.  Ivi.  p,  1. 
t A Case  of  Melanosis,  &c.  by  Thomas  Fawdington. 

The  Morbid  Anatomy,  Plate  XII. 

Z 


354 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


tellect,  give  rise  to  fatuity ; and  life  may  be  terminated  either  by 
coma,  with  or  without  convulsion,  or  by  a sudden  apoplectic  attack. 

2.  Most  of  these  organic  changes,  if  small  or  limited  in  extent, 
exercise  little  influence  on  the  functions  ascribed  to  the  brain.  Even 
when  large,  their  influence  seems  to  be  referable  chiefly  to  the  mor- 
bid changes  in  the  capillary  circulation  now  mentioned.  In  many 
instances  no  change  in  sensation,  intellect,  or  locomotion  is  induced 
till  within  a few  days  before  death,  when  the  convulsions,  palsy, 
and  coma,  which  preceded  this  event,  must  be  ascribed  chiefly  to 
vascular  injection  taking  place  a little  before  these  external  effects 
become  manifest. 

3.  The  situation  of  the  morbid  substance  and  of  the  disordered 
action  is  certainly  of  some  moment  in  modifying  the  effects  pro- 
duced. To  determine  the  influence  of  local  situation  in  this  respect 
attempts,  direct  and  indirect,  have  been  made  by  La  Peyronie,  Zinn, 
Lorry,  Haller,  and  Saucerotte,  and  more  recently  by  Rolando, 
Elourens,  Serres,  Bouillaud,  and  others.  Without  attempting  to 
inquire  into  the  merit  of  the  experimental  and  argumentative  inves- 
tigations of  these  authors,  I shall  merely  state  some  of  the  most  im- 
portant conclusions,  which  they  have  thought  their  researches  justified. 

1.  Injury  done  to  the  anterior  lobes  of  the  brain  causes,  accord- 
ing to  M.  Bouillaud,  more  or  less  loss  of  speech,  depending  either 
on  disorder  or  abolition  of  memory,  or  on  that  of  the  muscular  mo- 
tions of  the  organs  of  speech.* 

2.  According  to  the  observations  of  M.  Serresf  and  MM.  Fo- 
ville  and  Pinel  Grandchamp,  when  the  corpus  striatum,  that  is,  the 
anterior  part  of  the  striated  nucleus,  is  injured,  the  motions  of  the 
legs  are  disordered  and  impaired ; and  when  the  optic  thalamus,  or 
the  posterior  region  of  the  striated  nucleus,  is  injured,  the  motions 
of  the  arms  are  impaired. 

3.  Though  M.  Serres  has  endeavoured  to  demonstrate  the  posi- 
tion of  M.  Gall,  that  lesions  of  the  middle  lobe  of  the  cerebellum 
have  a particular  influence  on  the  generative  organs,  this  is  rendered 
very  doubtful  by  the  researches  of  Rolando,  Flourens,  and  especi- 
ally Bouillaud.  M.  Flourens  endeavours  to  show  that  the  cere- 
bellum regulates,  influences,  or  co-oi’dinates  the  voluntary  motions. 

* Recherches  Cliiiiques,  &c.  Par  M.  J.  Bouillaud,  D.  M.  Archives  Generales, 
Tome  viii.  p.  2.5.  Traite  Clinique  et  Physiologique,  p.  157-161.  Paris,  182,5  ; and 
Note  sur  une  article  de  M.  Pinel  Fils,  &c.  Journal  de  Physiol.  Tome  vi.  p.  19. 

+ Annuaire  Medico-Chirurgical  et  Journal  de  Physiologie,  Tome  III.  p.  123-128,  et 
ensuite. 


BRAIN. 


355 


Bouillaud  shows  that,  though  it  cannot  be  said  to  regulate  the  whole 
of  these  motions,  it  co-ordinates  those  concerned  in  equilibrium,  the 
state  of  rest,  and  the  different  forms  of  locomotion.  It  seems  fur- 
ther to  be  the  seat  of  a modification  of  memory,  that  of  voluntary 
motion.  When  disordered,  the  memory  is  obliterated,  the  motions 
are  impaired  or  disordered,  and  the  patient  exhibits  all  the  pheno- 
mena of  imbecility,  in  willing  any  regular  or  steady  motion,  or  in 
preserving  any  sensible  attitude  of  rest.* 

15.  Anencephalous  Malformation,  Deficiency  of  the  lohole  Brain 
or  of  its  parts.  {Enhephalelleipsis. ) — This  should  be  noticed  else- 
where, under  the  head  of  afiections  dependent  on  the  membranes 
and  blood-vessels.  But  it  may  render  the  history  of  the  abnormal 
states  of  the  brain  more  complete,  to  introduce  here  a short  account 
of  a species  of  malformation  arising  from  interruption  of  the  process 
of  development 

Instances  of  acephalous  foetuses,  as  they  have  been  named,  are 
numerous  from  the  first  records  of  anatomy  to  the  present  time. 
They  vary  in  degree  from  deficiency  of  the  whole  brain  to  that  of 
more  or  fewer  of  its  parts.  All  of  them  depend,  so  far  as  is  hither- 
to ascertained,  on  the  same  general  cause,  a sudden  check  given 
to  the  process  of  growth  in  this  organ  or  some  of  its  parts,  while  the 
others  continue  to  increase.  The  general  accuracy  of  this  conclu- 
sion is  established  by  the  researches  of  Meckel,f  of  Duncan,  Junior,  J 
of  Breschet,§  and  of  Serres.||  In  1835  I collected  from  different 
sources  several  cases,  in  order  to  illustrate  the  nature  of  the  malfor- 
mation, and  the  mode  in  which  it  is  effected  and  subsequently  the 
subject  bas  been  elucidated  by  Cruveilbier.** 

The  mode  in  which  the  growth  of  the  brain  is  arrested  may  be 
understood  from  the  history  of  the  progressive  development  of 
the  organ,  which  I have  above  stated  is  formed  by  deposition 
from  the  vascular  membrane,  commencing  near  the  centre  of  the 

■*  Recherches  Experimentales,  &C.  Par  J.  Bouillaud,  Merabre-Adjoint,  &c.  Archives 
Generales,  Tome  xv.  p.  64. 

t Handbuch  der  Pathologischen  Anatomie.  Von  J.  F.  Meckel.  Leipzig,  1812. 

J Case  of  Hydrocephalus  with  Bifid  Brain,  in  Medico-Chirui'gical  Trans.  Edin.  Vol.  i. 
p.  205. 

§ Note  sur  deux  enfans  nouveaux-nes  hydrocephales  et  manquant  de  cerveau-  Par 
J.  Breschet,  Journal  de  Physiologie,  Tome  ii.  p.  269.  Ilde  Note  sur  des  enfants  Nou- 
veaux-nes, &c.  Par  G.  Breschet,  Jour,  de  Phys.  Tome  iii.  232. 

II  Essai  sur  une  Theorie  Anatomique  des  IMonstrosites  Animates.  Revue  hledicale, 
Tome  vi.  p.  180.  Paris,  1821, 

*f  Edinburgh  Medical  and  Surgical  Journal,  Vol.  XLIV.  p.  527,  Oct.  1835. 

**  Cinquieme  Livraison  et  Huitieme  Livraison.  Paris,  1833. 


356 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


hemispheres,  and  proceeding  in  both  directions  towards  the  convo- 
luted and  the  central  surfaces.  When  the  process  of  nutritious 
deposition  is  arrested  at  an  early  period,  the  brain  is  entirely  want- 
ing, and  one  or  two  imperfectly  shaped  tubercles  only  denote  the 
site  of  the  corpora  quadrigeminn,  the  thalami,  or  the  protuberance. 
If  at  a later  period,  the  cerebellum  and  the  lower  part  of  the  brain, 
with  several  of  its  objects,  may  be  completed.  But  separating  the 
two  hemispheres  above,  there  is  found  a large  chasm,  filled  by  wa- 
ter, and  in  which  neither  mesolobe,  vault,  septum,  nor  thalami  can 
be  recognized.  This  interruption  M.  Sevres  ascribes  to  imperfect 
development  of  the  arterial  system  going  to  the  brain.  But  this  is 
only  a collateral  effect. 

In  some  instances  a hemisphere  is  wanting ; in  others  the  anterior 
lobe  is  deficient ; in  others  both  anterior  lobes  are  wanting;  and  in 
others  there  is  a general  diminution  in  the  size  of  one  whole 
hemisphere,  and  the  magnitude  of  its  component  convolutions,  while 
the  other  presents  its  normal  dimensions  and  proportions. 

All  these  phenomena  are  produced  in  the  same  way  and  proceed 
from  the  same  cause.  An  attack  of  meningeal  inflammation  or  hy- 
drocephalus in  the  womb,  before  birth,  or  immediately  after  that 
event, — not  sufficient  to  extinguish  life, — arrests  the  nutritive  action 
of  a certain  order  of  the  cerebral  capillaries.  The  nutritive  action 
is  employed  in  secreting  serous  fluid.  The  growth  of  part  of  the 
brain  affected  is  suddenly  stopped ; and  while  the  growth  of  the  rest 
advances,  that  remains  stationary. 

This  interruption  of  normal  action  of  vessels  depends  on  a sud- 
den change  somehow  effected  in  them,  in  consequence  of  which  the}' 
no  longer  continue  the  nutritious  process.  The  proof  that  the  im- 
perfect development  of  the  arterial  system  is  only  a collateral 
effect,  is  found  in  the  fact,  that  the  development  of  these  vessels  is 
always  equal  and  sometimes  superior  to  the  progress  of  the  abnormal 
action  and  its  effects. 

It  is  manifest  that,  in  cases  of  this  nature,  the  atrophy  of  the 
brain  is  not  a primary  or  idiopathic  lesion,  but  is  indeed  the  eflfect 
partly  of  the  excessive  distension  of  the  walls  of  the  brain  by  an 
extraordinary  quantity  of  fluid,  and  partly  of  mechanical  compres- 
ion  by  the  fluid  inducing  som.etimes  condensation  of  the  parts,  some- 
times softening,  but  always  more  or  less  destruction  of  the  proper 
structure.  Atrophy,  indeed,  is  one  of  the  effects  of  great  effusions 
of  fluid.  It  cannot  be  denied  that  in  cases  of  this  class  the  brain  is 
not  nourished,  or  is  even  deprived  of  nourishment.  But  it  must 

4 


BRAIN. 


357 


be  borne  in  mind  that  the  suspension  or  interruption  of  nutrition 
is  the  effect  of  a preceding  morbid  state,  in  which  the  blood-vessels, 
the  natural  nutrients  of  the  organ,  are  made  to  assume  a new  and 
perverted  action. 

From  the  cases  now  recorded  it  further  appears  that  the  atro- 
phied parts  of  the  brain  are  diminished  in  size  or  shrunk,  and  that 
they  also  cease  to  possess  their  characteristic  physical  and  physio- 
logical properties,  and  to  perform  their  functions  duly.  Thus  in 
all  the  cases  with  the  diminution  in  size  of  the  parts,  there  is  more 
or  less  loss  of  motion  and  sensation  in  some  of  the  voluntary  organs. 
Loss  of  memory  appears  occasionally  to  take  place ; but  loss  of  in- 
tellect is  not  invariable.  This,  however,  may  depend  on  the  part  of 
the  brain  atrophied,  and  on  the  extent  of  the  atrophy.  The  mental 
energy  is  generally  enfeebled ; but  the  most  characteristic  feature 
is  that  one  faculty  may  retain  considerable  force,  while  others  are 
disproportionately  weak.  The  intensity  of  the  intellect  is  unequal. 

This  is  a frequent  cause  of  congenital  idiocy,  surd- muteness,  palsy 
of  one  side  or  various  parts  of  the  body ; and  unequal  development 
of  several  organs. 

Often  one  or  more  members  may  be  shrunk,  withered,  and  pa- 
ralytic ; and  occasionally  one  side  is  hemiplegic. 

As  to  the  intimate  nature  of  the  change  induced  in  the  parts  so 
shrunk  and  diminished  we  have  as  yet  no  precise  information.  It 
may  arise  either  from  arrest  of  the  growth  of  the  parts,  or  from 
the  removal  of  parts  by  absorption,  or  rather  by  disruption  and 
breaking  down.  The  pressure  increased  by  the  presence  of  a new 
fluid  may  be  adequate  to  prevent  growth  of  the  parts  compressed, 
and  even  to  break  down  and  disorganize. 

Atrophy  of  the  brain,  therefore,  may  differ  according  as  it  takes 
place  during  the  process  of  development  or  after  that  process  is 
completed.  If  it  take  place  during  the  process  of  formation,  then 
that  process  is  suddenly  interrupted,  and  the  brain  presents  more 
or  fewer  of  its  parts  in  an  incomplete  or  rudimentary  state.  Thus 
in  cases  in  which  the  process  is  interrupted  previous  to  the  forma- 
tion of  the  convolutions,  and  in  which  serous  fluid  more  or  less 
copious  is  effused  from  the  nutrient  vessels,  the  brain  resembles  a 
shapeless  uniform  bladder  of  membranous  and  cerebral  matter  en- 
closing serous  fluid.  This  is  perhaps  the  most  complete  example 
of  the  atrophy  of  the  brain,  and  corresponds  with  the  agenesia  of 
M.  Cazauvieilh  (Archives  de  Med.  xiv.) 

The  parts  which  next  to  tliese  are  most  generally  wanting  are 


358 


GENERAL  AND  RATIiOLOGICAL  ANATOMY. 


the  meso-lobe,yb;■?^^a.•  and  septum  lucidum.  Reil  observed  the  want 
of  this  part  in  an  idiotic  female  who  had  attained  the  age  of  thirty 
years. 

Independently  or  along  with  themeso-lobe  and  fornix,  the  upper 
region  of  the  hemispheres  may  be  wanting  as  far  as  the  ceiling  of 
the  ventricles.  But  it  is  difficult  to  distinguish  the  atrophy  of  this 
part  from  atrophy  of  the  convoluted  surface  of  the  brain. 

Atrophy  may  next  affect  the  corpora  striata  or  optic  tlialami^  in 
the  form  of  diminished  bulk  and  general  dimensions,  proceeding 
to  such  extent  that  these  bodies  may  be  altogether  wanting. 

The  same  lesion  may  occur  in  the  cerebellum,  the  annvdar  pro- 
tuberance, or  in  the  peduncles  and  the  spinal  bulb. 

The  spinal  chord  or  vertebral  portion  of  the  brain  is  in  like 
manner  liable  to  atrophy,  both  during  the  process  of  developmenE 
and  after  its  completion. 

In  the  first  case  the  chord  is  entirely  or  partially  wanting,  and 
its  place  is  supplied  by  serous  fluid,  more  or  less  copious,  contained 
within  the  membranes.  Thus  in  many  cases  of  spina  bifida,  as  it 
is  denominated,  that  disease  is  the  effect  of  some  interruption  given 
to  the  process  of  growth  in  the  spinal  marrow,  by  reason  of  which 
the  arterial  action  is  expended  in  the  effusion  of  fluid,  which  fills 
and  distends  the  membranes,  prevents  the  further  deposition  of 
cerebral  matter,  and  preventing  also  the  union  of  the  spinal  plates 
on  the  mesial  plane,  gives  rise  to  a soft  elastic  tumour  at  the  most 
yielding  and  dependent  part  of  the  spinal  column.  In  general  the 
spinal  marrow  is  either  partially  or  entirely  wanting  in  some  part 
of  its  course  in  cases  of  this  kind.  Its  continuity  is  interrupted 
either  without  a single  trace,  or  with  a few  streaks  of  cerebral 
matter  on  the  one  side,  or  at  the  anterior  part  of  the  column,  M'hile 
the  vacancy  is  supplied  by  serous  fluid  or  shreds  of  cerebral  matter. 

In  other  instances  of  this  species  of  atrophy,  each  lateral  half  of 
the  chord  is  in  a very  slender  and  imperfect  form  of  development, 
and  is  separated  from  that  of  the  opposite  side  by  the  interposition 
of  serous  fluid.  In  cases  of  this  kind,  it  is  not  uncommon  to  find 
the  median  canal  persistent  long  after  birth,  imitating  in  this  respect 
the  structure  observed  in  the  spinal  chord  of  the  lower  animals^ 

It  may  be  doubted  whether  it  be  quite  correct  to  apply  the  term 
atrophy  to  those  lesions  of  the  spinal  chord,  in  which  the  breaking 
down,  the  softening  or  shrinking  of  the  parts,  is  evidently  due  to  in- 
flammatory action  excited  in  them  from  disease  of  the  membranous 

investments  or  the  bones.  Thus,  in  cases  of  disease  of  the  vertebrce, 

3 


]st:rvous  tissue. 


359 


inflammation  of  a chronic  character  is  very  soon  propagated  to  the 
membranes  and  the  chord,  and  part  of  it  is  softened  and  disorgan- 
ized. The  injury  may  not  be  suflficient  to  extinguish  life;  and 
after  some  time,  when  the  active  part  of  the  inflammatory  process 
has  subsided,  part  of  the  spinal  marrow  is  contracted  in  size,  and 
compressed  by  the  new  products ; and  this  constitutes,  according 
to  the  strict  understanding  of  the  term,  the  anatomical  characters 
of  atrophy.  In  admitting  this  application  of  the  term,  therefore, 
it  ought  to  be  distinctly  understood,  that  the  term  atrophy  desig- 
nates, not  a primary  lesion,  but  a lesion  which  is  the  effect  of 
another  previous  action.  Several  cases  of  the  kind  are  recorded 
by  Ollivier  and  others. 


CHAPTER  II. 

B.  The  Distributed  Part  of  the  Nervous  System. 

Section  I. 

NERVE,  NERVOUS  TISSUE. — (Nsu^ov, — Nervus, — Tissu  Nerveux, — 
Systeme  Nerveux.) 

The  structure  of  the  nerves  has  been  examined  with  different 
degrees  of  accuracy  and  minuteness  by  a great  number  of  anato- 
mists. The  more  ancient  authors,  who  wrote  at  a period  when  ob- 
servation was  much  corrupted  by  fancy,  and  most  of  those  who  give 
descriptions  in  general  systems,  maybe  without  much  injustice  passed 
over  in  silence.  It  is  sufficient  to  say,  that  some  good  facts  are 
given  in  the  works  of  Willis,*  Vieussens,f  Morgagni, j;  and  Mayer  ;§ 
that  Prochaska,|]  Pfeffinger,!!  and  the  second  Monro,**  are  the  first 
who  professedly  wrote  on  the  structure  of  the  nerves ; that  the 

■*  Thomas  Willis,  Cerebri  Anatome  Nervorumque  Descriptio  et  Usus.  Amsterdam, 
1682. 

-f-  Raymimdi  Vieussens  Neurographia  Universalis.  Lyon,  168-1. 

i Adversaria  Anatomica,  4to.  Lugduni  Bat.  1 723. 

§ J.  C.  Mayer  Abhandlung  vom  Gehirn,  Ruckenmark,  und  dem  Ursprunge  der  Ner- 
ven.  Berlin,  1779. 

II  Georgii  Prochaska  de  Structura  Nervorimi  Tractatus  Anatomicus.  Vienna,  1779 
and  1800,  ap^ld  Op.  Minora. 

H Jo.  Pfeffinger,  de  Structura  Nervorum.  In  Ludwig,  Scriptomm  Neurolotr. 
Select.  Tom.  I. 

■**  Monro  on  the  Structure  and  the  Functions  of  the  Nervous  System.  Edinburgh, 
1783.  Folio. 


360 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


works  of  Reil,*  Bichat,  and  Gordon,  contain  the  most  accurate 
information  on  the  nervous  chords  in  general ; and  that  the  trea- 
tises of  Scarpaf  and  W utzerj  contain  the  most  satisfactory  infor- 
mation on  the  arrangement  of  those  parts  named  ganglions  and 
plexus.  Lastly,  by  the  microscopic  researches  of  Ehrenberg,  Tre- 
viranus,  Muller,  Valentin,  Weber,  and  Remak,  some  facts,  though 
rather  discordant,  have  been  communicated  on  the  minute  structure 
of  the  nervous  filaments. 

Each  nerve  forms  connections  in  three  different  ways ; IV,  A 
nerve  must  be  connected  to  some  part  of  the  central  mass  by  one 
of  its  extremities, — the  cerebral  or  spinal  end ; 2d,  It  must  be  con- 
nected to  some  texture  or  organ,  or  part  of  an  organ  by  the  other 
extremity, — the  organic  end;  and,  Zd,  It  may  be  connected  to 
other  nerves  by  a species  of  junction  called  anastomosis,  (ansa) — 
anastomosing  or  uniting  point.  By  means  of  the  two  first  connec- 
tions, it  is  supposed  to  maintain  a communication  between  the  cen- 
tral mass  and  the  several  organs ; and  by  the  latter  it  is  understood 
to  be  subservient  to  a more  general  and  extensive  intercourse,  which 
is  believed  to  be  necessary  in  various  functions  and  actions  of  the 
animal  syst  nn. 

Every  nerve  consists  essentially  of  two  parts ; one  exterior,  pro- 
tecting and  containing ; the  other  interior,  contained,  and  func- 
tional, forinii'g  the  indispensable  part  of  the  nervous  structure. 

The  first  of  these,  which  has  been  known  since  the  time  at  least 
of  Reil  by  the  name  neurilema,  (nv^civ,  hXew,  nervi  involucrum,) 

or  nerve-coat,  (Nervenhaut,  Reil ; Nervenhulle,  Meckel;)  has  the 
form  and  nature  of  a dense  membrane,  not  quite  transparent,  which 
is  found  on  the  outside  of  the  nervous  chord  or  filament,  and  in- 
vests the  proper  nervous  substance.  It  must  not,  however,  be 
imagined  that  the  neurilema  forms  a cylindrical  tube,  in  the  inte- 
rior of  which  the  nervous  matter  is  contained.  This  latter  disposi- 
tion, if  it  actually  exists,  applies  to  the  smaller  nerves  only,  and  to 
some  of  those  which  go  to  the  organs  of  sensation, — a peculiarity 
which  we  shall  notice  subsequently. 

Any  large  nervous  trunk,  for  example,  the  spiral  or  median  of 
the  arm,  or  the  sciatic  nerve  of  the  thigh,  is  found  to  be  composed 

* J.  C.  Reil,  Exercitationes  Anatomicae  de  Structura  Nervorum.  Haller,  1797 

T Anatoinicarum  .Annotationum,  Lib.  Prim,  de  Nervorum  Gangliis  et  Plexibus. 
Auctore  Antonio  Scarpa. 

J De  Corporis  Humani  Gangliorum  Fabrica  atque  Usu,  Monograpliia.  Auctore 
Carolo  Gulielmo  Wutzer,  Med.  Chirurg.  Doct.  &c.  Berolini,  1817- 


NERVOUS  TISSUE. 


361 


of  several  small  nervous  chords  placed  in  juxtaposition,  and  each 
of  which,  consisting  of  appropriate  neurilema  and  nervous  substance, 
is  connected  to  the  other  by  delicate  filamentous  tissue.  These, 
however,  do  not,  through  their  entire  course,  maintain  the  parallel 
disposition  in  respect  to  each  other,  but  are  observed  to  cross  and 
penetrate  each  other,  so  as  to  form  an  intimate  interlacement  of  ner- 
vous chords  and  filaments,  each  of  which,  however  minute,  is  accom- 
panied with  its  investing  neurilema.  The  neurilema,  in  short,  may 
be  represented  as  a cylindrical  membranous  tube,  giving  from  its 
inner  surface  many  productions  foi’ming  smaller  tubes ; ( Canaliculi, 
Die  Nervenrohre  ; primitive  cylinders  of  Fontana  ;*)  in  which  the 
proper  nervous  matter  is  contained. 

Of  this  arrangement  the  consequence  is,  that  each  nerve  or  ner- 
vous trunk,  enveloped  in  its  general  neurilema,  is  composed,  never- 
theless, of  a number  more  or  less  considerable  of  smaller  chord- 
like nervous  threads  {funiculi  nervei,  Prochaska;  chordcc,  funes^ 
Nervenstraenge,  Reil,)  into  which  the  nerve,  by  maceration  and 
suitable  preparation,  may  be  resolved.  Each  chord,  again,  or 
nerve-string^  as  Reil  terms  it,  though  invested  with  a proper  nuri- 
lem,  may  be  further  resolved  into  an  infinite  number  of  minute  fili- 
form or  capillary  filaments,  {Fila,  fibrillce,  Nervenfasern,  Reil,) 
which,  invested  in  a delicate  covering,  are  understood  to  constitute 
the  ultimate  texture  of  the  nerve. 

This  threefold  division  may  be  easily  observed  in  the  brachial 
and  spiral  nerves  of  the  arm,  and  still  more  distinctly  in  the  sciatic 
in  the  thigh.  The  utility  of  understanding  the  internal  arrange- 
ment from  which  it  results  will  appear  forthwith,  when  the  struc- 
ture of  those  parts  termed  ganglions  and  plexuses  comes  under 
examination. 

Of  this  arrangement  in  different  nerves,  and  in  different  regions, 
this  membrane  undergoes  great  modification  ; and  all  opinions  on 
its  nature  derived  from  thickness  or  transparency  are  liable  to  con- 
siderable fallacy.  Scarpa  seems  to  view  it  as  connected,  in  ana- 
tomical origin  and  character,  with  the  hard  membrane,  {meninx 
dura^  dura  mater.)  Reil,  who  devoted  more  care  and  time  to  the 
examination  of  its  nature  and  structure  than  any  other  inquirer, 
represents  it  as  consisting  of  cellular  substance,  many  blood-vessels, 
and  some  lymphatics.f  Bichat  thought  it  resembled  the  soft  mem- 

* Observations  sur  la  strUctiu'e  des  Nerfs,  &c.  apud  Traite  sur  le  Venin,  &c.  par  M. 
Felix  Fontana. 

•f  De  Structura  Nervorum,  cap.  i.  p.  3. 


362 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


brane  of  the  brain,  {{pia  meninx,  pia  mater,')  and  was  derived  from 
it.*  Gordon  considers  the  neurilema  of  the  cerebral  nerves  as  con- 
sisting of  soft  membrane,  {pia  mater)  at  their  origin,  but  in  all 
other  situations  as  a species  of  cellular  membrane. 

By  Mayer  the  neurilema  is  accounted  a fibrous  tissue,  for  the 
following  reasons.  Is?,  It  consists  almost  entirely  of  tendinous 
fibres,  and  is  cellular  only  where  it  is  very  thin.  2r/,  The  trans- 
verse folds  presented  by  most  of  the  nerves,  and  which  give  them 
a dentilated  form,  are  derived  from  the  neurilema,  are  of  fibrous 
character,  and  are  similar  to  those  observed  in  tendinous  sheaths. 
3fZ,  Several  nervous  productions  are  actually  converted  into  tendi- 
nous or  fibrous  filaments;  for  example,  the  brain  of  the  snail  tribe,  {li- 
maqons,)  and  the  spinal  chord  both  in  these  and  other  animals  at  the 
cauda  equina.  4?/i,  The  neurilema  is  either  a continuation  of  the  pro- 
per cerebral  membrane,  {pia  mater,)  or  very  similar  to  it ; and  this 
membrane  is  fibrous  and  aponeurotic  at  the  spinal  chord,  and  even 
at  its  upper  end,  and,  according  to  Mayer,  forms  the  denticulated 
ligament,  which  is  a fibrous  tissue.f 

These  views,  which  are  the  result,  not  of  observation,  but  of  hy- 
pothesis, it  is  impossible  to  adopt.  Its  connection  with  the  jna  mater 
was  disproved  by  Reil ; and  though  its  analogy  with  the  denticu- 
lated ligament  were  established,  it  would  prove  nothing  regarding 
the  neurilema.  Upon  the  whole,  the  idea  communicated  by  Reil 
is  the  most  probable.  According  to  the  observations  of  this  ana- 
tomist, who  examined  the  neurilema  after  fine  and  successful  injec- 
tion, it  is  liberally  supplied  with  blood-vessels.  These  derived  from 
the  neighbouring  arteries  penetrate  the  filamentous  sheath  of  the 
nerve : and,  immediately  on  reaching  the  neurilema,  divaricating 
at  right  angles,  generally  run  along  the  nervous  threads,  {funes,) 
parallel  to  them,  forming  numerous  anastomotic  communications, 
and  divide  into  innumerable  minute  vessels,  which  penetrate  between 
them  into  the  minute  neurilematic  canals.  So  manifold  is  the  ra- 
mification, and  so  perfect  the  distribution,  that  in  these  canals  not 
a particle  of  nervous  substance  is  found  which  is  not  supplied  with 
a vessel. j;  The  arrangement  of  the  veins  is  analogous. 

It  appears,  therefore,  that  the  neurilema  is  a tissue  of  membra- 

* Anatomic  Generale,  p.  137,  &c. 

-I  Discours  sur  I’Histologie,  par  le  Docteur  Mayer.  Bonn,  1819,  Journal  de  Ale- 
decine,  Vol.  XIII.  p.  99.  1 822. 

J Joannis  Christian!  Reil,  Exercitationum  Anatom,  de  Structura  Nervorum,  cap.  .5, 


NERVOUS  TISSUE. 


363 


nous  form,  with  a multiplied  mechanical  surface,  liberally  supplied 
with  blood-vessels,  from  which  the  nervous  matter  is  secreted  and 
nourished.  It  is  impossible,  indeed,  to  doubt,  that  of  the  two  parts 
which  compose  the  nervous  chord,  it  is  the  most  perfectly  organized; 
and  that,  though  it  may  not  be  similar  in  structure  to  the  pia  mater, 
it  is  quite  analogous  in  the  use  to  which  it  is  subservient.  Like 
that  membrane,  it  sustains  the  vessels  of  the  nerve ; it  presents  a 
multiplied  surface,  over  which  the  vessels  are  distributed  ; and  by 
penetrating  deep  into  the  body  of  the  nerve,  it  conveys  the  nutri- 
tious vessels  in  the  most  capillary  form  to  the  inmost  recesses  of 
the  nervous  substance.* 

The  arrangement  which  has  been  above  described  is  the  only 
one  which  can  be  regarded  as  general.  It  varies  in  particular  re- 
gions ; and  these  varieties  in  the  neurilematic  disposition  occur 
principally  in  the  nerves  which  are  distributed  to  the  proper  organs 
of  sensation.-f-  Is^,  The  olfactory  nerve  is  soft,  pulpy,  and  desti- 
tute of  neurilema,  from  its  origin  in  the  sylvian  fissure,  to  the  gray 
bulbous  enlargement  which  terminates  its  passage  in  the  cranium  ; 
but  as  soon  as  it  reaches  the  canaliculi  or  grooves  of  the  ethmoid 
bone,  and  begins  to  be  distributed  through  the  nasal  anfractuosities, 
it  is  distinctly  neurilematic.  2d,  The  optic  nerve  is  still  more  pe- 
culiar in  this  respect.  The  instant  it  quits  the  optic  commissure, 
{commissura  tractuum,'}  it  begins  to  be  invested  by  a firm  general 
neurilema,  which  sends  into  the  interior  substance  of  the  nerve  va- 
rious membranous  septa  or  partitions,  forming  separate  canals,  in 
which  the  nervous  matter  is  contained.  These  partitions,  however, 
are  so  thin,  that  at  first  sight  the  optic  nerve  seems  to  consist  mere- 
ly of  one  exterior  membranous  cylinder  inclosing  the  proper  mem- 
branous substance.  3(f,  Lastly,  we  remark,  that  the  auditory 
nerve,  or  the  soft  portion  of  the  seventh  pair  of  most  anatomical 
writers,  the  eighth  pair  of  Soemmering,  is  the  only  nerve  in  which 
this  covering  cannot  be  traced. 

The  neurilema  is  much  thinner  and  more  delicate  in  the  nerves 
which  are  distributed  to  tbe  internal  organs,  as  the  lungs,  heart, 
stomach,  &c.  (nerves  of  the  organic  life,  great  sympathetic  and 
pneumogastric  nerves,  par  vagum),  than  in  those  belonging  to  the 
muscular  system. 

The  second  component  part  of  the  nervous  chord  or  filament  is 

* Reil,  ibid.  chap.  i. 

t By  the  term  “ proper  organs  of  sensation”  is  understood  those  of  sight,  hearing, 
Smell  and  taste,  which  are  confined  to  a fixed  spot  in  tlie  system. 


364 


GENIiRAL  AND  PATHOLOGICAL  ANATOMY. 


the  proper  nervous  matter  which  occupies  the  cavity  of  the  neurile- 
matic  canals.  Little  is  known  concerning  the  nature  or  oreaniza- 
tion  of  this  substance.  It  is  whitish,  somewhat  soft,  and  pulpy ; 
but  wbether  it  consists  of  aggregated  globules,  as  was  attempted  to 
be  established  by  Della  Torre  and  Sir  Everard  Home,  or  of  linear 
tracts  disposed  in  a situation  parallel  to  each  other,  as  appears  to 
be  the  result  of  the  inquiries  of  Monro,  Reil,  and  others,  or  of  ca- 
pillary cylinders  containing  a transparent  gelatinous  fluid,  as  Fon- 
tana represents,  seems  quite  uncertain.  It  has  been  presumed, 
rather  than  demonstrated,  that  it  resembles  cerebral  substance. 
But  this  analogy,  though  admitted,  would  throw  little  light  on  the 
subject ; for  at  present  it  is  almost  impossible  to  find  two  anatomi- 
cal observers  who  have  the  same  views  of  the  intimate  nature  of 
cerebral  substance  itself.  Whatever  be  its  intimate  arrangement, 
it  appears  to  be  a secretion  from  the  neurilematic  vessels.  (Reil.) 

The  structure  of  the  nervous  chord  may  be  demonstrated  in  the 
following  manner.  When  a portion  of  nerve  is  placed  in  an  alka- 
line solution,  the  whole,  or  nearly  the  whole,  of  the  nervous  mat- 
ter is  softened  and  dissolved,  or  may  be  washed  out  of  the  neurile- 
matic canals,  which  are  not  affected  by  this  agent,  and  the  disposition 
of  which  may  be  then  examined  and  demonstrated.*  Aqueous 
maceration  may  likewise  be  advantageously  employed  to  unfold  this 
structure ; for  it  separates  and  decomposes  the  cellular  tissue  by 
which  the  neurilematic  canals  are  united,  and  subsequently  occa- 
sions decomposition  of  the  nervous  substance,  while  it  leaves,  at 
least  for  some  time,  the  neurilema  not  much  affected.  When,  how- 
ever, the  maceratioTi  is  too  long  continued,  it  is  separated  and  de- 
tached like  other  macerated  textures. 

Lastly,  If  a large  nerve  be  placed  in  diluted  acid  for  the  space 
of  one  or  two  weeks,  the  neurilema  is  gradually  dissolved,  and  the 
nervous  matter  becomes  so  much  indurated  and  consolidated  that 
it  may  be  separated  from  the  contiguous  chords  in  filaments  with 
great  facility.*  In  undergoing  this  change  the  portion  of  nerve 
becomes  much  shorter  and  considerably  contracted, — is  subjected, 
in  short,  to  the  process  of  crispation ; so  that  unless  a large  nerve 
like  the  sciatic  be  employed  for  the  experiment,  it  may  be  impossible 

* J.  C.  Reil  de  Structura  Nervorum,  cap.  i.  p.  3 and  5. 

T According  to  the  experiments  of  Reil,  nitrous  acid  diluted  rvith  water  answers  best. 
Muriatic  acid,  though  equal  or  even  superior  in  effecting  solution  of  the  neurilema, 
softens  the  nervous  matter  too  much,  and  separates  the  component  filaments  too  com- 
pletely.— De  Structura,  cap.  iii.  p.  16. 


NERVOUS  TISSUE. 


365 


to  obtain  the  result  in  the  most  satisfactory  form.  These  experi- 
ments, with  many  others  of  the  same  nature,  were  first  performed 
by  Professor  Reil,  and  afterwards  repeated  and  varied  by  Bichat 
and  by  Dr  Gordon.  Personal  repetition  of  them  enables  me  to 
assert,  that,  when  correctly  conducted,  they  never  failed  to  give  the 
results  as  described  by  these  authors. 

Nervous,  tissue,  like  all  others,  receives  a proportion  of  what  may  be 
denominated  the  systems  of  distribution, — cellular  tissue  and  blood- 
vessels. In  the  substance  of  the  former,  the  disposition  of  which 
we  have  already  remarked,  we  find  the  more  conspicuous  branches 
of  the  latter  distri  buted.  In  a more  minute  and  divided  form  they 
penetrate  the  neurilema  and  nervous  substance.  Reil,  who  derived 
his  conclusions  from  the  result  of  delicate  and  successful  injections, 
perhaps  overrated  the  quantity  of  blood  which  in  the  sound  state 
they  convey;  for  it  is  quite  certain,  that,  in  the  healthy  state,  hardly 
any  red  blood  enters  the  nervous  tissue,  as  may  be  easily  shown  by 
exposing  the  sciatic  nerve  of  a dog  or  rabbit. 

No  good  chemical  analysis  of  nervous  matter  has  yet  been  pub- 
lished. Every  chemical  examination  of  it  has  been  conducted  on 
the  assumption  that  it  is  analogous  to  cerebral  matter.  Of  this,  how- 
ever, there  is  no  direct  proof.  In  the  analysis  by  Vauquelin  the 
neurilematic  covering  appears  not  to  have  been  detached, — a pro- 
ceeding always  necessary  to  obtain  correct  results  in  this  inquiry. 
The  effects  of  acids  and  alcohol  show  that  it  contains  albuminous 
matter ; but  beyond  this  it  is  impossible  at  present  to  make  any  pre- 
cise statements. 

This  description  may  communicate  an  idea  of  the  structure  of  the 
nervous  chord  in  general.  In  particular  situations  this  structure  is 
considerably  modified.  The  modifications  to  which  we  allude  occur 
under  two  forms — ganglions  (Die  knoten ;)  and  plexuses  (Die  Ner- 
vengeflechte. ) 

Every  ganglion  consists  essentially  of  three  parts ; 1st,  an  exte- 
rior covering;  2d,  a collection  of  minute  nervous  filaments;  and, 
3d,  a quantity  of  peculiar  cellular  or  filamentous  texture,  by  which 
these  filaments  are  connected,  and  which  constitutes  the  great  mass 
of  the  ganglion. 

The  ganglions  are  of  two  kinds,  the  spinal  or  simple,  and  the 
non-spinal  or  compound.  These  two  kinds  of  bodies  differ  from 
each  other,  Is^,  in  the  situation  which  they  respectively  occupy;  2d, 
in  the  kind  of  envelope  with  which  they  are  invested ; 3d,  in  the 
mode  in  which  the  nervous  filaments  pass  through  them  and  from 


36G 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


them.  By  Wutzer,  who  considers  the  ganglion  of  Gasserius,  the 
ciliary  and  the  maxillary  of  Meckel,  as  cerebral  ganglions,  they  are 
divided  into  three  sets,  those  of  the  cerebral  system,  the  spinal  sys- 
tem, and  the  vegetative^  or  those  connected  with  the  organs  of  invo- 
luntary motion.* 

Void  of  the  dense  strong  coat  with  which  the  others  are  invested, 
the  cerebral  ganglions  consist  of  soft  secondary  matter,  connected 
to  the  filaments  of  one,  or  at  most  two  branches,  and  are  arranged 
with  less  complexity.  (Wutzer.) 

The  spinal  ganglions  are  said  to  possess  two  coverings,  one 
of  which  resembles  the  hard  cerebral  membrane,  {ineninx  dura^ 
the  other  the  soft  cerebral  membrane,  [meninx  tenuis^  pia  mater.') 
The  non-spinal,  or  compound  ganglions,  have  also  two  coverings, 
which  are  merely  different  modifications  of  filamentous  tissue  less 
dense  and  compact  than  in  the  former.  Both  these  sets  of  ganglions 
being  by  maceration  stripped  of  their  tunics,  and  deprived  of  the 
soft  pulpy  cellular  matter,  are  resolved  into  an  innumerable  series 
of  nervous  threads,  most  of  which  are  minute  and  scarcely  percep- 
tible ; all  are  continuous  with  the  nerve  or  nerves  above  and  below 
the  ganglion.  It  appears  that  the  nervous  chord,  when  it  enters 
the  one  apex  of  the  ganglion,  begins  to  be  separated  into  its  com- 
ponent threads,  which  diverge  and  form  intervals,  between  which 
the  delicate  cellular  tissue  is  interposed ; and  that  these  filaments 
are  subsequently  collected  at  tbe  opposite  extremity  of  the  ganglion, 
where  they  are  connected  with  the  other  nerve  or  nerves.  Scarpa, 
to  whom  we  are  indebted  for  the  most  of  the  knowledge  we  possess 
on  this  subject, t compares  the  arrangement  to  a rope,  the  compo- 
nent cords  of  which  are  iintwisted  and  teased  out  at  a certain  part. 
Lastly^  In  the  simple  ganglions,  the  filaments  of  which  they  con- 
sist, invariably  follow  the  axis  of  the  ganglion;  but  in  the  compound 
ones  they  are  found  to  rise  towards  the  sides  and  emerge  from  them ; 
and  upon  this  variety  in  the  direction  and  course  of  these  filaments 
depends  the  variety  of  figure,  for  which  these  two  orders  of  gan- 
glions are  remarkable.  These  nervous  threads  {stamina  s.Jila  ner- 
vea)  described  by  Scarpa,  correspond  to  the  medullary  filaments 
(fila  niedullaria ) of  Wutzer.  According  to  this  anatomist  these 
filaments,  when  about  to  enter  the  ganglion,  lay  aside  their  neurilem ; 
yet  they  are  sufficiently  tough  to  resist  a certain  degree  of  tension. 

* De  Corporis  Ilumani  Gangliorum  Falarica,  &c.  cap.  i.  ii.  § 41,  jr.  S2. 

t Anatomicarum  Annotationum  Liber  Primus  de  Nervorum  Gangliis  et  Plexiibus. 
Auct.  Ant.  Scarpa. 


NERVOUS  TISSUE. 


3G7 


Wiitzer  mentions  a cluster  of  vesicles  or  cells  (cancelli)  in  the 
filamentous  tissue  of  the  ganglion.  But  he  was  not  enabled  by  any 
means,  mechanical  or  chemical,  to  ascertain  their  exact  nature. 

The  ganglions  are  well  supplied  with  blood-vessels,  derived  in 
general  fi’om  the  neighbouring  arteries.  The  intimate  distribu- 
tion is  represented  by  Wutzer  to  be  the  following.  The  artery 
proceeding  to  a ganglion  gives  vessels  to  the  filamentous  tissue ; 
and,  perforating  the  proper  coat,  is  immediately  ramified  into  in- 
numerable minute  canals,  the  first  order  of  which  forms  vascular 
nets  on  the  inner  surface  of  the  tunic ; while  the  residual  twigs 
penetrate  the  flocculent  texture,  and  the  individual  vesicles  of  the 
secondary  or  filamentous  matter  of  the  ganglion.* * * § 

This  short  exposition  of  the  structure  of  the  ganglions  shows  the 
mistaken  notions  of  Johnstone,  Unzer,  Bichat,  and  others,  on  the 
structure  and  uses  of  these  bodies.  The  idea  first  advanced 

by  Johnstone,t  and  Unzer, J adopted  by  Metzger,§  Hufeland,|| 
Prochaska,^  Sue,  and  Harless,**  and  afterwards  applied  with 
much  ingenuity  by  Bichat,  that  the  ganglions  are  so  many  nervous 
centres  or  minute  brains,  is  disproved  by  strict  anatomical  observa- 
tion. 2d,  That  they  are  connected  with  the  order  of  involuntary 
actions,  and  influence  these  actions,  appears  to  be  the  only  inference 
that  can  at  present  be  admitted  regarding  them.  Ganglions  are 
not  observed  on  any  of  the  nerves  proceeding  to  organs  of  volun- 
tary motion.  Sensation,  circulation,  nutrition,  and  secretion  are 
the  functions,  over  which  they  preside.  Sd,  Lastly,  we  remark,  as 
a circumstance  of  some  importance,  that  the  only  difference  between 
a ganglion,  and  any  other  part  of  a nervous  chord,  is,  that  in  the 
former  the  minute  nervous  filaments  appear  to  be  uncovered  with 
neurilema,  and  lodged  in  a mass  of  cellular  tissue,  which  is  then 
inclosed  in  the  neurilematic  capsule ; while  in  the  latter  each  ner- 
vous filament  has  its  appropriate  neurilema,  and  the  cellular  tissue, 
instead  of  being  within,  is  on  its  exterior,  and  connects  it  to  the 
contis:uous  filaments. 

O 

* De  Corporis  Humani  Gangliorum  Fabrica,  &c.  cap.  ii.  § 41. 

f Philosophical  Transactions,  V'ol.  LIV.  LVII.  and  LX.  and  Essay,  &c. 

t J.  A.  Unzer,  Physiologic  thierischer  Korper.  Leipzig,  1771,  p.  66. 

§ I.  D.  Metzger  Opuscula  Anatomica  et  Physiolog.  Gothas,  &c.  1790. 

II  C.  W.  Hufeland  Ideen  uber  Pathogenic,  &c.  Jena,  1795. 

^ G.  Prochaska  Lehrsatze  der  Physiologic,  &c.  I.  ter  Band.  “Wien,  1797. 

**  J.  J.  Sue,  Recherches  Physiologiques,  &c.  Paris,  an.  vi.  German  Translation 
bv  I.  C.  F.  Harless,  1797,  p.  2.  Nurnberg,  1799,  p.  .3. 


368 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


In  various  situations  two,  three,  or  more  nervous  trunks  or  chords 
mutually  unite  hy  means  of  some  of  their  component  threads,  and 
after  proceeding  in  this  manner  for  a short  space,  again  separate, 
but  not  in  the  same  number  of  original  trunks,  or  preserving  the 
same  appearance.  In  general,  the  number  of  chords  into  which 
they  finally  separate  is  greater  than  that  of  which  they  consisted 
before  union.  Three  or  four  nervous  trunks,  for  example,  after 
uniting  in  this  manner,  will  form  on  their  final  separation  five  or 
six  nerves  or  nervous  chords ; and  it  is  quite  impossible  to  deter- 
mine which  of  the  latter  order  was  derived  from  any  one  or  two  of 
the  former,  or  what  number  of  individual  chords  it  has  received 
from  each.  Between  the  two  points  also,  the  first  point  of  union, 
and  the  last  of  separation,  many  of  the  more  minute  component 
threads  are  detached  from  two  or  more  of  their  trunks,  and  after 
first  uniting  with  each  other  in  an  indistinct  network,  are  again 
united  to  two  or  more  of  the  nervous  chords  near  the  point  at 
which  they  finally  separate  from  the  further  end  of  union.  This 
arrangement  has  been  termed  a plexus,  plait,  or  weaving,  in  conse- 
quence of  the  manner  in  which  the  nervous  chords  are  interlaced 
or  plaited  together.  The  arrangement  which  we  have  noticed  as 
consisting  of  the  more  minute  nervous  threads  has  been  called  a 
smaller  plexus  •,  {plexus  minor.)  It  is  a subordinate  plexus  within 
a larger  one. 

The  best  and  most  distinct  example  of  a plexus  is  that  commonly 
named  the  brachial  or  axillary.*  This,  as  is  well  known,  is  situate 
in  the  space  contained  between  the  broad  dorsal  muscle  {latissimus 
dorsi)  behind,  and  the  great  pectoi’al  muscle  before,  and  is  formed 
in  the  following  manner.  The  fifth,  sixth,  seventh,  and  eighth 
cervical  nerves,  and  the  first  dorsal,  after  forming  the  usual  con- 
nections, {ansae,)  pass  downwards  from  the  vicinity ^of  the  vertebrae 
between  the  middle  and  anterior  scaleni  muscles,  and  nearly  opposite 

* Imo  nullibi  fortasse  clarior  atque  evidentior  est  hsec  multarum  conjugationum 
nervearum  consociatio  atque  commixtio,  quam  in  hac  nervorum  spinalium  implicatione 
plexwm  hrachialem  appellata.  Ibi  enini  quinque  memorati  nervi  spinales  cervicales 
una  convenientes,  qua  primum  cohaerent,  aut  tribuunt  aut  mutuo  dant  et  accipiunt  a 
sociis  stamina,  quae  demum  in  plures  ramos  consociata  de  plexu  exeuntes  brachiorum 
nervos  faciunt  ex  omnibus  illis  quinque  conjugationibus  spinalibus,  aut  ex  earum  pie- 
risque,  composites.  Atque  exinde  sequitur,  ut  nervi  brachiales  dicti,  qui  a plexu  ad 
brachium,  manum  digitosque  ejus  omnes  derivant,  minime  ad  unam,  sed  ad  plures 
spinalium  conjugationes,  nempe  ad  quatuor  cervicales  inferiores  et  dorsalium  primum 
pertineant. — Anatom.  Annotation,  cap.  iii.  § 9.  pp.  4. 


NERYOUS  TISSUE. 


369 


the  lower  margin  of  the  seventh  cervical  vertebra,  or  about  the  level 
of  the  first  rib,  begin  to  be  united  by  the  component  threads  of 
each  nerve.  Threads  of  the  fifth  and  sixth  cervical  unite, — some- 
times to  form  a single  chord ; in  other  instances  to  be  connected  a 
short  space  onward  with  threads  of  the  seventh  cervical  in  a similar 
manner.  The  seventh  and  eighth  form  two  kinds  of  union.  "When 
the  seventh  is  large,  it  divides  almost  equally  into  two  chords  or 
branches,  one  of  which  is  connected  first  with  the  fifth  and  sixth, 
afterwards  with  the  eighth,  and  with  the  first  dorsal  by  interlace- 
ment of  minute  nervous  threads.  The  other  either  passes  down- 
ward to  form  one  of  the  separate  brachial  nerves,  or  is  also  con- 
nected with  the  eighth  cervical  and  first  dorsal  in  a plexiform 
manner. 

From  this  arrangement  immediately  arise  the  individual  nervous 
branches  which  form  the  nerves  of  the  arm,  and  which  are  named 
brachial  nerves.  The  interlacement  of  minute  nervous  threads  be- 
tween the  seventh  and  eighth  cervical,  and  the  first  dorsal,  is  what 
Scarpa  has  termed  the  plexus  minor.  He  says  it  is  peculiar,  in  be- 
ing quite  uniform,  and  in  connecting  those  nervous  branches 
which,  from  their  subsequent  destination,  are  called  IMedian  and 
Ulnar. 

This  description,  though  not  generally  applicable,  will  commu- 
nicate some  faint  idea  of  the  nervous  unions  and  interlacements 
termed  plexus  or  weavings.  For  more  minute  information  on  the 
distribution,  arrangement,  and  configuration  of  this  part  of  the 
nervous  system,  I refer  to  the  work  of  Scarpa  already  quoted.* 

Plexiform  arrangements  are  not  confined  to  the  exterior  regions 
of  the  body.  They  are  more  numerous  internally ; and  almost  all 
the  organs  of  the  chest  and  belly  have  each  a plexus,  sometimes 
two,  from  which  they  derive  their  nervous  chords. 

Plexiform  arrangements  are  generally  situate  in  the  neighbour- 
hood of  blood-vessels,  and  in  some  instances  inclosing  considerable 
arterial  trunks  more  or  less  accurately.  Thus  the  axillary  plexus 
surrounds  the  axillary  artery.  The  cceliac  artery  is  surrounded 
with  the  solar  plexus : and  the  coronary,  hepatic,  splenic,  supe- 
rior mesenteric,  and  renal,  are  also  surrounded  with  plexiform 
nervous  filaments.  In  some  instances  these  nervous  filaments  are 
so  intimately  connected  with  the  arterial  tubes  as  to  lead  some 

* Annotation.  Anatom.  § 9.  cap.  iii.  pp.  94,  95. 

A a 


370 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


anatomists  to  consider  them  as  forming  a peculiar  net-work  sur- 
rounding the  vessel,  and  to  exercise  great  influence  on  the  circu- 
lation. (Wrisberg,  Ludwig,  and  Haase.) 

It  is  remarkable  that  the  structure  of  the  nervous  chords  which 
form  a plexus,  has  either  appeared  so  simple  as  not  to  demand  par- 
ticular attention,  or  is  so  obscure  as  to  be  never  noticed.  Have 
the  nervous  chords  and  threads  in  such  situations  their  usual  enve- 
lope ? Is  the  nervous  matter  in  the  chords  quite  the  same  as  in 
other  situations  ? Is  there  any  other  means  of  union,  save  the 
nervous  substance  itself?  We  believe  there  is  no  doubt  that  every 
chord  in  a plexus  is  provided  with  its  neurilema  as  in  other  plaees  ; 
but  this  neurilema  is  generally  thinner  and  more  delicate ; and  the 
general  neurilema  seems  to  be  wanting.  Its  mechanical  properties 
of  cohesion  and  resistance  have  not  been  examined. 

The  view  which  has  been  given  of  the  structure  or  arrangement 
of  the  nervous  plexus  has  led  Scarpa  to  consider  them  as  nearly 
allied  to  ganglions.  The  same  separation  of  the  component  threads 
or  filaments  of  the  nerve  or  nerves,  the  same  interlacement,  and  the 
same  or  similar  formation  of  new  chords,  appear  to  take  place  in 
both  orders  of  structure.  A ganglion,  indeed,  he  conceives,  is  a 
condensed  or  contracted  plexus ; and  a plexus  is  an  expanded  or 
unfolded  ganglion.  The  great  anatomical  purpose  of  both  appears 
to  be  simply  a new  arrangement  or  disposition  of  nervous  branches, 
previous  to  their  ultimate  distribution  in  the  tissues  or  organs  to 
which  they  are  destined.  This  is  nothing  but  the  expression  of  a 
fact, — the  interpretation  in  intelligible  terms  of  an  arrangement  of 
organized  parts  without  reference  to  any  supposed  \ises. 

The  minute  structure  of  the  nerves  has  been  examined  by  Fon- 
tana, Prochaska,  Bauer,  Ehrenberg,  Valentin,  Muller,  Wagner, 
and  Remak. 

M.  Bauer  found  the  optic  nerve  to  consist  of  many  bundles  of 
very  delicate  fibres,  connected  together  by  means  of  a jelly-like, 
transparent,  semifluid,  viscid  substance,  easily  soluble  in  water. 
These  fibres  consisted  of  globules,  which  are  from  to  ^g^gth 

part  of  an  inch  in  diameter,  with  a few  at  gg^octh  part  of  an  inch  in 
diameter,  the  latter  being  the  size  of  the  red  globules  of  the  blood 
deprived  of  colouring  matter.  The  retina  appeared  like  a conti- 
nuation of  the  bundles  composing  the  optic  nerve,  consisting  of  the 
same  sized  globules  connected  into  fibrous  lines,  and  forming  bun- 
dles radiating  from  the  end  of  the  nerve  to  the  circumference  of 

4 


NERVOUS  tisslt;. 


371 


the  retina,  where  they  disappear,  terminating  in  smooth  mem- 
brane.* 

The  olfactory,  optic,  and  auditory  nerves,  Ehrenberg  found  to 
consist  of  varicose  or  moniliform  medullary  tubules,  directly  con- 
tinued from  the  moniliform  tubes  of  the  white  cerebral  matter. 
The  moniliform  tubules  of  the  olfactory  nerves  are  the  thickest 
known,  and  vary  fi'om  leijlh  to  juoth  part  of  a line  in  diameter. 
Those  of  the  optic  nerve  are  smaller,  being  from  gnotii  to  j^gth 
part  of  a line  in  diameter  ; and  tubules  of  the  same  dimensions  are 
observed  in  the  chiasma  or  decussation,  in  which  the  tubes  are  re- 
presented crossing  each  other ; while  the  retina  consists  of  articu- 
lated tubules  so’soth  part  of  a line  in  diameter,  traversing  medul- 
lary grains  about  jgoth  part  of  one  line  in  diameter.  It  contains 
also  mace-like  or  club-shaped  bodies. 

The  structure  of  the  auditory  nerve  is  also  peculiar.  The  sim- 
ple tubules  of  this  nerve  Ehrenberg  found  considerably  thicker  than 
those  of  the  others,  and  the  spheroidal  enlargements  or  ampullulos 
flatter  and  less  prominent,  yet  everywhere  distinctly  seen.  In  other 
respects  it  was  similar  to  the  olfactory  and  optic  nerves. 

The  great  sympathetic  nerve,  in  like  manner,  consists  of  articu- 
lated cerebral  tubules  ; but  there  is  a mixture  of  simple  cylindri- 
cal tubes  at  each  extremity. 

The  nerves  now  specified,  the  olfactory,  optic,  auditory,  and 
great  sympathetic,  are  articulated  or  moniliform  nerves. 

All  the  other  nerves  consist,  not  of  articulated  or  moniliform 
tubes,  but  of  simple  cylindrical  tubules,  somewhat  larger,  being 
from  iloth  to  ijoth  part  of  one  line  in  diameter.  These  tubules  are 
surrounded  and  inclosed  by  vascular  networks,  and  contained  within 
ligamentous  or  neurilematic  partitions ; and  they  contain  a medullary 
substance,  semifluid,  but  capable  of  expression  from  them,  and  coa- 
gulation within  their  interior.  These  are  tubulated  nerves.f 

The  ganglia  vary  in  structure.  All  consist  of  articulated  or 
bead-like  cerebral  tubules,  which,  either  alone,  as  in  the  chiasma, 
form  the  knot,  or,  as  in  all  the  ganglia  of  the  sympathetic  examined, 
are  mingled  with  large  cylindrical  nervous  tubules,  inclosed  within 
a close  slender  vascular  network,  between  the  meshes  of  which  are 
deposited  granules  similar  to  those  observed  in  the  retina. 

* Philosophical  Transactions,  1821  and  1824. 

t Beobachtung  einer  auffaUenden  bishcr  unbekannte  structur  des  Seelenorgan  im 
Menschen  undThieren  ; and  Edin.  Med.  and  Surg.  Journal,  VoL  XLVIII.  p.  282. 


372 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


The  tubules  and  cylinders  now  specified,  which  correspond  with 
the  primitive  cylindei’s  of  Fontana,  are  merely  in  juxtaposition,  and 
do  not  intermingle  in  substance  with  each  other. 

The  general  accuracy  of  the  facts  now  stated  has  been  confirmed 
by  Muller,  Krause,  Wagner,  and  Remak.  Neither  Ehrenberg 
nor  Muller  have  been  able  to  recognize  in  the  roots  of  the  sensi- 
ferous  and  motiferous  nerves  any  essential  difference  in  microsco- 
pical structure. 

In  the  hypoglossal  and  glossopharyngeal  nerves  are  seen  only 
cylindrical  tubes. 

I have  already  shown  what  is  meant  by  tbe  organic  end  or  ter- 
mination of  a nerve.  Althougb  the  nervous  trunks  are  distributed 
in  every  direction  tbrougb  the  animal  body,  they  do  not  terminate 
in  all  tbe  tissues  or  organs  indiscriminately ; and  have  been  observed 
to  be  lost  in  tbe  following  only.  Is?,  the  proper  organs  of  sensa- 
tion, the  eye,  ear,  nose,  palate,  and  tongue ; 2d,  the  muscles,  whe- 
ther subservient  to  voluntary  or  to  involuntary  motion,  as  the  heart, 
stomach,  intestines,  &c. ; 3(f,  the  mucous  surfaces;  Atli,  the  skin  ; 
5th,  glands,  salivary,  liver,  kidneys,  &c. ; Qth,  bones. 

Nerves,  therefore,  are  not,  strictly  speaking,  organs  of  general 
distribution.  According  to  Bichat,  they  have  never  been  traced 
to  the  following  tissues  : — the  cartilages,  both  articular  and  of  the 
cavities ; fibrous  textures,  viz.  peidosteum,  dura  meninx,  capsular 
ligaments,  aponeurotic  sbeaths,  aponeurosis  in  general,  tendon  and 
ligament ; fibro-cartilaginous  textures ; those  of  the  external  ear, 
nose,  trachea,  and  eyelids,  (cartilages  of  other  authors) ; the  semi- 
lunar cartilages  of  the  knee-joint ; those  of  the  temporo-maxillary 
articulatioir ; those  of  the  intervertebral  spaces ; marrow ; the 
lymphatic  glands. 

To  this  we  may  add  the  testimony  of  a professed  anatomist  of  the 
nervous  system,  whose  reputation  for  patient  and  industrious  re- 
search cannot  fail  to  sanction  every  thing  which  he  has  advanced. 
“ In  every  subject,”  says  Walter  of  Berlin,  “ in  which  I was  desir- 
ous to  trace  the  nerves,  I injected  the  arteries  with  red-coloured 
wax,  the  veins  with  green,  and  even  the  lymphatics  with  quicksilver, 
so  that  I was  able  to  distinguisb  the  nervous  filaments  from  each 
of  these  orders  of  vessels.  By  this  contrivance,  though  it  occupied 
much  time  and  labour,  yet  I was  satisfactorily  convinced  that  the 
pleura,  the  pericardium,  the  thoracic  duct,  and  the  peritoneum,  re- 
ceive no  nerves.  Nay,  that,  contrary  to  the  opinions  of  the  most 


NERVOUS  TISSUE. 


373 


eminent  recent  anatomists,  no  nerves  terminate  in  the  lymphatic  or 
conglobate  glands.  Sometimes,  indeed,  these  organs  are  perforated 
by  one  or  two  twigs,  as  I have  often  had  occasion  to  observe ; but 
they  instantly  proceed  to  the  next  place  assigned  to  them,  and  in 
which  they  are  finally  lost,”*  If  after  this  conclusion  of  Walter 
personal  testimony  can  be  of  any  use,  I may  add,  that  I have  exa- 
mined the  dura  mater^  the  periosteum,  and  most  of  the  synovial 
membranes  repeatedly,  to  discover  nervous  filaments  in  them,  and 
always  without  success  ; and  I may  say  the  same  regarding  the  ab- 
sence or  non-appearance  of  nerves  in  the  peritoneum  and  pleura. 

The  nerves  have  different  uses  in  the  different  organs  and  tissues 
to  which  they  are  distributed.  1.  In  the  organs  of  sensation  they 
receive  the  mechanical  impressions  made  on  the  mechanical  part  of 
the  organ.  In  the  eye,  the  retina  receives  the  last  image  formed 
by  the  transmitting  powers  of  the  transparent  parts.  In  the  ear, 
the  terminations  of  the  auditory  nerve  are  affected  by  the  oscilla- 
tions or  minute  changes  in  the  fluid  of  the  labyrinth,  occasioned  by 
the  motions  of  the  tyrapantil  bones.  In  the  mucous  membrane  of 
the  nasal  passages,  the  filaments  of  the  olfactory  nerve  are  affected 
by  aromatic  particles,  dissolved  or  suspended  in  the  air.  In  the 
palate,  tongue,  and  throat,  the  gustatory  nerves  are  affected  by 
sapid  bodies  dissolved  in  the  mouth,  or  applied  in  a fluid  state  to 
the  mucous  membrane  of  that  cavity,  2.  In  the  system  of  volun- 
tary muscles  the  nerves  retain  the  action  of  the  muscular  fibres  in 
a state  of  uniformity  and  equality,  and  keep  them  obedient  to  the 
will.  In  the  involuntary  muscles  they  appear  merely  to  keep  their 
action  equable,  regular,  and  uniform ; and  in  both  they  maintain 
a communication,  or  consent  or  harmony  of  action  between  different 
parts  of  the  same  system  of  organs,  or  even  between  different  organs 
concurring  to  the  same  function.  3.  In  the  glandular  organs  the 
nerves  certainly  exercise  some  influence  over  the  process  of  secre- 
tion ; but  what  is  the  exact  nature  of  this  influence,  or  in  what  de- 
gree it  takes  place,  is  quite  uncertain. 

When  we  observe  the  nerves  distributed  to  organs  of  sensation 
and  organs  of  motion,  it  is  a natural  thought  to  inquire  whether  the 
nerves  minister  to  both  functions,  and  whether  different  nerves  or 
different  sorts  of  nerves  minister  to  each  function.  It  seems  to  have 
been  an  idea  of  considerable  antiquity,  that  one  set  of  nerves  are 
sensiferous,  and  another  set  motiferous.  Erasistratus  derives  the 

* Praefat.  Tab.  Nerv.  Thoracis  et  Abdominis,  J.  G.  Walter. 


374 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


nerves  of  motion  from  the  brain  and  cerebellum,  and  those  of  sen- 
sation  from  the  membranes ; and  Galen  distinguishes  the  nerves 
into  Nsvga  AiaDirixa  and  K/v»jr/^a,  the  former,  soft,  from  the 

brain,  the  latter,  hard,  from  the  spinal  marrow.  This  distinction 
was  not  altogether  lost  sight  of  among  the  anatomists  and  physio- 
gists  of  the  eighteenth  century  ; but  it  was  rather  maintained  as  a 
probable  speculation,  than  elucidated  and  enforced  as  an  established 
doctrine,  pregnant  with  important  results.  It  was  recognized  by 
Glisson,  and  taught  by  Boerhaave,*  and  received  and  promulgated 
by  his  pupils,  Tissot  and  Van  Eems;f  but  opposed  by  HallerJ  and 
Cullen.  The  distinction  was,  nevertheless,  maintained  by  Lecat, 
Morin,  and  Pouteau,  the  last  of  whom  was  led  from  various  examples 
of  persons,  who,  after  injuries,  had  lost  sensation,  but  retained  the 
power  of  movement,  to  espouse  it  with  considerable  energy.§ 

In  1784  George  Prochaska,  Professor  of  Anatomy  at  Vienna, 
published  on  the  functions  of  the  nerves  a commentary,  in  which 
he  gave,  after  Plaller,  Caldani,  Whytt  and  Unzer,  a more  precise 
and  correct  view  of  the  uses,  properties,  and  powers  of  these  or- 
gans, than  had  hitherto  been  formed.  In  this  commentary  he  fully 
recognizes  the  distinction  between  sensorial  nerves  or  those  devoted 
to  sensation,  and  motific  nerves  or  those  ministering  to  motion ; 
he  shows  that  sensorial  impressions  or  impressions  made  on  the  sen- 
sitive nerves,  are  reflected  or  transmitted  in  a reflex  direction  to  the 
motific  nerves ; that  the  latter  nerves  are  thereby  excited  to  action  ; 
that  the  purpose  of  this  reflex  operation  is  the  preservation  of  the 
individual ; and  that  the  whole  are  under  the  influence  of  the  Sen- 
sorium  Commune.  Pie  distinctly  states,  that  this  reflected  action  is 

■*  Prselectiones  Academicse  in  proprias  Institutiones  Rei  Aleclicse,  Editaeet  Notis  Auc- 
ta,  ab  Alb.  Haller.  VII.  Toini.  l"2mo.  Goettingae,  1745. 

T Hermann!  Boerhaave,  Phil,  et  Med.  Doct.,  &c.  Pralectiones  Academic®  de  Mor- 
bis  Nervorum,  Quas  ex  Manuscriptis  collectas  edi  curavit  Jacobus  Van  Eems,  Medi- 
cus  Leydensis.  Tome  I.  and  II.  Lugduni  Batavor.  1761.  “ Omnes  (nervi)  inser- 

viunt  motui  vel  famulantur  sensui  ; sed  in  illis  qui  cordi,  pulmoni,  hepati,  aliisque 
partibus  vitalibus  destinati  sunt,  sensus  non  deprehenditur.  Qui  motui  inserviunt, 
abeunt  ad  musculos,  et  in  iis  ita  mollescunt,  ut  in  verum  quasi  cerebrum  degenerent. 
Ramuli,  qui  sensibus  famulantur,  in  ipsis  organis  mollitie  fere  difHuunt,  uti  patet  in 
expansione  nervi  optici,  olfactorii,  ubi  se  applicat  ad  os  ethmoides,  et  acoustic!  in  laby- 
rintho,”  p.  261. 

+ Elementa  Physiologise,  Liber  X.  Sect.  VIII.  § xxii.,  Tomus  Quartus,  p.  389. 

§ Memoire  et  Recherches  sur  la  difference  a etablir  entre  les  nerfs  du  sentiment  et 
les  nerfs  du  mouvement,  a I’occasion  de  quelques  observations  sur  cette  espece  rare 
de  paralysie,  qui  prive  un  membre  de  tout  sentiment,  sans  lui  oter  I’usage  du  mouve- 
ment. Oeuvres  Postumes  de  M.  Pouteau,  Docteur  en  Medecine  et  Chirurgien  en  Chef 
de  I’Hotel-dieu  de  Lyon.  Tome  II.  p.  480.  Paris,  1789. 


NERYOUS  TISSUE. 


375 


not  regulated  by  physical  laws,  where  the  angle  of  reflection  is 
equal  to  the  angle  of  incidence,  but  obeys  peculiar  laws  impressed 
by  nature,  as  it  were,  on  the  sensor ium,  and  which  laws  we  can 
understand  from  their  effects  alone.  This  reflex  action  further 
takes  place  either  without  or  with  the  consciousness  of  the  soul. 
The  motion  of  the  heart,  stomach,  and  intestines,  is  independent  of 
the  cognizance  of  the  soul ; and  in  many  other  instances  of  senso- 
rial impressions  being  transmitted  to  motific  nerves,  though  the  soul 
is  conscious,  it  can  neither  prevent  them  nor  promote  them.* 

The  commentary  of  Prochaska  is  the  first  precise  view  of  the 
functions  of  the  nervous  system  in  modern  times ; and  the  first  in 
which  the  automatic  and  instinctive  phenomena  enumerated  by 
Whytt  are  referred  to  a reflex  operation. 

In  1811,  Sir  Charles  Bell,  in  a tract  containing  the  Idea  of  a New 
Anatomy  of  the  Brain,  stated  that  he  had  proved  experimentally  that 
“ the  posterior  fasciculus  of  spinal  nerves,  which  are  gangliophorous, 
might  be  detached  from  its  origin  without  convulsing  the  muscles 
of  the  back  ; whereas,  on  touching  the  airterior  fasciculus  with 
the  point  of  the  knife,  these  muscles  were  immediately  convulsed.” 
From  this  it  seemed  a probable  inference  that  gangliophorous  nerves 
had  no  concern  in  motion,  and  that  nerves  void  of  ganglion  mini- 
stered in  some  way  to  that  fnnction. 

In  1818,  Charles  Francis  Bellingeri  published  at  Turin,f  a Dis- 
sertation treating,  among  other  subjects,  of  the  anatomy  and  phy- 
siology of  the  fifth  and  seventh  pairs  of  nerves.  In  this  he  showed 
that  the  great  portion  of  the  fifth  pair  or  trifacial  nerve,  which  forms 
the  large  semilunar  plexus  called  Gasserian  ganglion,  is  a nerve, 
not  of  motion  but  of  sensation ; that  its  three  branches  are  distri- 
buted to  certain  parts  of  the  eye,  the  nasal  cavities,  the  palate  and 
tongue ; ministering  in  these  parts  not  to  motion,  but  to  sensation, 
and  probably  to  circulation,  nutrition,  and  secretion ; and  that  the 
small  branch  of  that  nerve  (jiervus  masticatorius),  is  distributed  to 
muscles,  (temporalis,  masseter,  pterygoideus,  buccinaiorius,')  and  is  a 

* Georgii  Prochaska,  M.  D.,  Professoris  Anatomice,  Physiologise  et  Storborum  Ocu- 
lorum  in  Universitate  Vinclobonensi,  Operum  jMinorum.  Pars  II.  Vienn®,  1800. 
8vo.  Commentatio  de  Functionibus  Systematis  Nervosi. 

-)-  Caroli  Francisci  Bellingeri  E.  S.  Agatha  Derthonensi.  PhiL  et  Med.  Doct.  Am- 
plessim  Med.  Collegii  Candidati  Dissertatio  InauguraUs  quam  public®  defendebat. 
In  Athenaeo  Regio  Anno  MDCCCXVIII.  Die  IX.  Maii  ; hora  IX.na.  matutina. 
August®  Turinorum.  8vo.  1818.  Ex  Anatome  ; De  Nervis  Faciei  ; Ex  Physiologia  ; 
Quinti  et  Septimi  Paris  Functiones,  «Scc. 


376 


GENERAL  AND  rATHOLOGICAL  ANATOMY, 


nerve  of  motion.  He  also  showed  that  the  seventh  pair,  or  late- 
ral facial,  presides  over  sensation  and  m otion  in  the  functions  of  the 
head,  face,  and  neck,  but  mostly  over  motion. 

In  1821,  Sir  Charles  Bell  undertook  to  establish  the  principle, 
that  of  the  two  nervous  trunks  distributed  to  the  face,  viz.  the  trige- 
minus^ or  fifth  cerebral  nerve,  and  the  portio  clura^  or  seventh  cere- 
bral nerve,  the  lateral  facial,  the  former  presides  over  the  sensations 
or  common  sensibility  of  the  head  and  face ; that  it  also  possesses 
branches  going  to  the  muscles  of  mastication ; whereas  the  latter  nerve 
regulates  the  muscular  motions  of  the  lips,  nostrils,  and  velum palati, 
and  especially  in  associated  action  with  the  motions  of  respiration. 

About  the  same  time  Magendie  claimed  the  merit  of  showing 
experimentally  the  fact  of  the  distinction  between  nerves  minister- 
ing to  sensation  and  nerves  ministering  to  motion,  and  of  proving 
that,  of  the  double  row  of  nervous  roots  issuing  in  parallel  lines  from 
the  lateral  regions  of  the'  spinal  chord,  the  anterior  are  destined  for 
motion,  and  the  posterior  for  sensation. 

Lastly,  Mr  Mayo,  partly  by  dissection,  partly  by  experimental 
inquiry  and  reasoning,  arrived  at  the  conclusion  that  almost  all  the 
bi’anches  of  the  large  or  gangliophorous  portion  of  the  trifacial 
nerves  are  nerves  of  sensation,  while  those  of  the  small  fasciculus, 
which  is  void  of  ganglion,  are  nerves  of  motion. 

In  this  manner,  by  successive  steps,  has  been  established  one  of 
the  most  important  doctrines  on  the  functions  of  the  nervous  chords 
in  modern  physiology ; and  its  justice  h;js  been  confirmed  by  the 
labours  of  many  observers.  The  distinction  is  most  clearly  proved 
by  the  original  experiment  of  Sir  Charles  Bell.  If  the  spine  be 
laid  open,  especially  in  a cold-blooded  animal,  as  a frog,  and  the 
posterior  or  gangliophorous  roots  alone  be  irritated,  no  movement 
is  produced ; but  the  moment  the  anterior  roots  are  touched,  the 
extremities  are  agitated  by  active  convulsive  motions. 

Of  the  cerebral  nerves,  the  first  or  olfactory,  the  second  or  optic, 
and  the  eighth  or  auditory,  are  pure  nerves  of  proper  sensation, 
and  are  distributed  to  the  sensitive  parts  of  the  eye,  the  nasal  cavi- 
ties, and  the  cochlea  and  labyrinth  respectively.  The  third,  fourth, 
and  part  of  the  sixth,  or  abducent,  are  motific  nerves  connected 
with  the  movements  of  the  eye.  The  fifth  or  trifacial  is  a very  pe- 
culiar nerve.  The  gangliophorous,  or  rather  plexiforra  part  of  it, 
communicates  with  all  the  organs  of  proper  sensation, — the  eye, 
the  ear  in  a small  degree,  the  nasal  cavities  largely,  and  the  palate. 


NERVOUS  TISSUE. 


377 


mouth,  and  tongue  largely  ; and  it  is  distributed  extensively  along 
with  the  minute  arteries  of  the  face.  Of  this  arrangement  the  re- 
sult is,  that  it  is  a nerve  neither  of  vision,  nor  of  hearing,  of  smell 
nor  of  taste,  or  deglutition  nor  of  touch,  or  physiognomical  expres- 
sion, exclusively,  but  over  the  whole  of  these  faculties  and  their 
proper  organs  exercises  a general  modulating  power.  It  maintains 
between  them  a mutual  consent  or  harmony  of  action,  absolutely 
necessary  to  the  due  separate  exercise  of  each  and  the  conjoined  ex- 
ercise of  all.  Lastly,  by  accompanying  the  arteries  of  the  face,  it 
regulates  the  circulation  of  that  region,  and  may  he  the  means  of 
maintaininsr  between  the  brain  and  the  facial  circulation  those  con- 

O 

ditions  and  expressions  which  arise  from  various  mental  emotions ; 
as  paleness,  blushing,  indignation,  the  sense  of  joy,  triumph,  the 
sublime,  and  similar  emotions. 

Not  less  peculiar  is  the  seventh,  the  small  sympathetic  of  Wins- 
low, Though  mostly  a motiferous  nerve,  yet  it  ministers  to  mo 
tions  of  a particular  order.  It  is,  however,  as  a nerve  distributed 
to  the  skin  of  the  face,  a nerve  contributing  to,  if  not  regulating 
animal  sensation  and  involuntary  motion.  It  is,  in  fact,  as  shown 
by  Wrisberg,  a double  nerve,  the  large  portion  of  which  is  devoted 
to  the  purposes  of  animal  life,  and  the  small  one  to  those  of  organic 
life.  It  is  a musculo-cutaneous  nerve  of  the  head  and  face. 

In  proceeding  further  in  explaining  the  respective  functions  of 
the  nerves,  it  is  requisite  to  keep  in  view  not  only  their  ganglio- 
phorous  character  and  the  reverse,  but  their  position  as  anterior 
and  as  posterior  nerves,  and  nerves  consisting  of  anterior  and  pos- 
terior roots. 

The  ninth  pair,  (iiervus  glosso-pharyngaus,)  consists  of  two  parts, 
one  large,  completing  sensation  to  the  root  of  the  tongue  and  pha- 
rynx, the  other  smaller,  moving  the  pharynx,  and  connected,  not- 
withstanding, with  the  tenth  pair,  pneumogastric,  and  the  great 
sympathetic. 

The  tenth  pair,  {nervus  vagus,)  or  pneumogastric  nerve,  is  chiefly 
a sensiferous  nerve,  regulating  the  sensations  of  the  larynx,  the 
oesophagus  and  stomach,  and  the  lungs,  and  placing  these  organs 
in  harmony  as  to  function.  One  particularly,  the  recurrent 
branches,  appear  to  be  motiferous.  All  the  other  brauches  appear 
to  regulate  circulation  and  secretion. 

To  the  accessory  nerve,  or  eleventh  pair,  seems  to  belong  the 
function  of  placing  the  pulmonary  and  laryngeal  divisions  of  the 


378 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


pneumogastric  in  harmony  and  relation  with  the  external  muscles 
of  the  hack  and  lateral  regions  of  the  neck. 

Lastly,  the  hypoglossal,  or  twelfth  pair,  having  mostly  an  anterior 
origin,  are  motiferous.  They  form  the  motiferous  nerves  of  the 
muscles  of  the  tongue. 

It  is  to  he  observed,  nevertheless,  that  though  this  distinction  in 
functions  belongs  to  particular  nerves,  yet  nerves  ministering  to 
sensation,  and  regulating  organic  or  involuntary  functions,  and 
nerves  ministering  to  motion,  and  regulating  either  voluntary  mo- 
tions, instinctive  motions,  or  involuntary,  but  associated  and  neces- 
sary motions,  are  often  closely  connected,  and  proceed  together  in 
the  same  sheath,  or  in  close  apposition  to  the  same  organ.  This, 
which  is  observed  in  the  fifth,  the  seventh,  the  ninth,  tenth,  and 
eleventh,  is  rendered  necessary  by  the  offices  which  the  organs  have 
to  perform.  The  impulse  or  impression  is  communicated  to  the 
organ,  and  received  by  its  sensiferous  nerves.  By  these  the  proper 
sensation  is  transmitted,  and  the  motiferous  nerves  are  excited  to 
action.  This  appears  to  he  the  mode  in  which  such  actions  as 
sneezing,  coughing,  yawning,  deglutition,  and  numerous  other  in- 
stinctive and  associated  actions  are  called  into  operation. 

Of  the  spinal  nerves  it  is  almost  superfluous  to  speak  after  the 
explanations  now  given.  The  splanchnic  or  great  sympathetic  ap- 
pears to  he  a nerve  of  organic  sensibility  and  impression,  and  as 
such  regulates  the  circulation  of  the  abdominal  organs,  and  trans- 
mits their  impressions  to  the  central  connections.  The  further 
continuance  of  these  by  its  spinal  connections  establishes  a har- 
monic action  with  the  spinal  marrow,  always  for  good  purposes,  but 
often  under  disease  producing  painful  and  destructive  etfects.* 

This  may  he  said  to  comprehend  all  that  is  accurately  known 
regarding  the  uses  of  the  nerves.  Every  other  doctrine  relating 
to  sensibility,  sympathy,  irritability,  &c.  is  either  unfounded,  not 
proved,  or  altogether  imaginary  and  hypothetical. 

In  the  foetus  the  nerves  are  developed  with  remarkable  perfec- 
tion. I cannot  speak  from  personal  observation  much  earlier  than 
the  sixth  month,  when  I have  found  the  nerves  of  the  extremities 

* For  further  information  and  illustrations  of  the  principles  now  stated,  I refer  the 
reader  to  Arnold’s  Illustrations  of  the  Nerves  of  the  Head  and  Face,*  and  an  account 
of  the  same  work  in  the  forty-thu’d  volume  of  the  Edinbiu’gh  Medical  and  Surgical 
Journal,  January  IdJo,  p.  22S. 


* Frederici  Arnold!  leones  Nervorum  Capitis.  Heidelbergse,  1834.  Folio. 


NEEVOUS  TISSUE. 


379 


and  voluntary  muscles  large  and  distinct.  At  the  eighth  mouth 
they  are  still  more  conspicuous.  The  anterior  crural  nerves  are 
in  the  form  of  flat  white  cords  one  and  a-half  line  hroad,  and  their 
branches  like  good  sized  threads.  The  sciatic  is  still  more  distinct. 
In  the  form  of  a thick  cylindrical  cord,  fully  a line  in  diameter, 
and  not  unlike  a piece  of  whip-cord,  it  is  tough,  stringy,  and  resists 
tension,  and  its  constituent  threads  are  well  marked.  I immersed 
a portion  of  this  nerve  three  and  a-half  inches  long  in  aqua  po- 
tassce,  when  it  first  became  much  firmer  and  denser  than  before, 
assumed  in  two  days  the  satin  fibrous  appearance  first  described  by 
Fontana,  and  at  length  by  solution  of  the  nervous  matter  was  se- 
parated into  chords  and  neurilematic  canals.  In  this  state,  pre- 
served in  spirit  of  turpentine,  it  conveys  a tolerably  correct  idea  of 
the  arrangement  of  the  neurilematic  canals. 

The  nerves  of  the  involuntary  muscles  are  equally  distinct  in 
proportion.  Those  of  the  lung,  heart,  and  splanclmic  system  are 
distinct  and  manifest  at  the  eighth  month. 

The  neurilem  is  much  more  vascular  in  the  foetus  than  in  the 
adult.  In  the  same  foetus  of  about  eight  months  I found  the  neu- 
rilem of  the  sciatic  nerve,  from  the  ischiatic  notch  to  its  divarica- 
tion in  the  ham,  covered  with  a thick  net-work  of  m.inute  vessels, 
all  injected  with  dark  blood. 

• 

Section  II. 

1.  Inflammation^  spontaneous  and  from  injury, — Nerve-ach,  Neu- 
ritis. Neuralgia.  (Neurilemmiaj  Various  observers,  asBoerhaave, 
have  doubted  the  spontaneous  occurrence  of  inflammation  of  a 
nerve  (neuritis;)  and  certainly  the  disease  is  not  very  common. 
Others,  on  the  contrary,  have  gone  to  the  opposite  extreme,  and 
thought  that  it  was  a frequent  affection.  Peter  Frank,  for  instance, 
and  Joseph  Frank,  maintain  that  there  is  no  doubt  that  neuritis 
arises  spontaneously,  and  that  it  is  a lesion  not  uncommon;  and  in 
this  they  are  supported  by  the  testimony  of  Nasse,  Nicod,  and  other 
authorities.  It  is  nevertheless  as  a primary  affection,  and  not  in- 
duced by  injury,  or  previous  disease  of  the  bones,  or  of  the  soft  tex- 
tures, not  very  frequent. 

When  it  takes  place,  the  morbid  action  may  affect  either  the 
nerve-coat  or  the  nervous  matter,  or  both.  In  the  first  case  the 
neurilema  is  thickened,  hardened,  and  rendered  rigid.  The  ner- 


380 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


vous  matter  is  also  enlarged ; and  often  a perceptible  enlargement 
is  formed  at  the  point  at  which  this  morbid  orgasm  is  established. 
Lymph  and  blood  are  also  effused;  and  to  this,  indeed,  the  enlarge- 
ment is  owing.  Inflammation  of  the  neurilema  is  certainly  a com- 
mon accompaniment,  if  not  a cause  of  neuralgic  pain. 

When  inflammation  affects  the  nervous  matter,  it  may  produce 
softening  from  slight  effusion  of  serum  or  suppuration,  or  indura- 
tion from  the  effusion  of  lymph.  Our  knowledge  of  these  effects 
is  obtained  mostly  either  from  injuries  of  nerves,  as  when  they  are 
torn,  bruised,  or  divided,  or  from  observing  the  results  of  experi- 
ments on  the  lower  animals.  In  this  point  of  view,  I shall  have 
occasion  to  recur  to  the  subject  afterwards. 

Nervous  tissue,  therefore,  is  liable  to  inflammation.  Tins  may 
arise  spontaneously,  or  inconsequence  of  injury,  as  contusion,  wound, 
laceration,  ligature,  &c.  It  is  accompanied  first  with  gnawing  pain, 
which  is  oftener  periodical  than  constant,  spreading  along  the  course 
of  the  nerve,  sometimes  its  branches,  with  a sense  of  heat  often  very 
disagreeable,  and  a peculiar  tenderness  of  the  surface.  After  some 
time  the  pain  is  less  violent,  but  more  constant ; and  more  or  less 
dei’angement  iii  the  functions  of  the  parts  to  which  the  nerve  goes 
takes  place.  The  skin  becomes  numb,  cold,  and  insensible.  Of 
muscular  parts  the  motions  are  variously  disordered,  becoming  ir- 
regular, spasmodic,  and  little  under  the  influence  of  the  will,  s^as 
to  constitute  convulsions,  and  finally  being  lost  in  different  degrees, 
so  as  to  cause  palsy  more  or  less  complete.  This  constitutes  one 
form  of  neuralgia  or  nerve-ach.  It  is  most  frequent  in  the  sciatic, 
partly  in  consequence  of  its  exposed  situation,  and  sometimes  in 
consequence  of  actual  violence  locally  inflicted,  as  in  falling.  {Is- 
cliias  nervosa  of  Cotunnius.)  I have,  however,  seen  this  affection 
arising  in  other  nerves;  for  example,  the  median  or  spiral,  in  the 
arm,  and  sometimes  the  posterior  tibial,  in  the  leg,  in  consequence 
of  similar  causes.  In  one  instance  it  was  confined  with  accuracy 
to  the  anterior  branch  of  the  radial  nerve,  which  goes  to  the  thumb 
and  index  finger.  In  such  cases  the  inflammatory  action  is  con- 
fined pretty  accurately  to  a part  of  the  neurilematic  coat,  which  be- 
comes firm,  vascular,  and  more  or  less  tender. 

In  neuralgia  of  the  face  {tic  doloureux,  Yothev^xW^)  {prosopalgia, 
Frank,  Weisse,)  it  is  not  easy  to  say  what  is  the  pathological  cause. 
It  is  undoubted  that  it  is  seated  in  the  nerve ; and  though  some 
forms  of  this  malady  evidently  depend  on  inflammation  of  the  neu- 


NERVOUS  TISSUE. 


381 


rilema,  yet  others  of  them,  which  are  of  long  continuance,  and  are 
attended  by  other  peculiarities,  are  not  perhaps  to  be  ascribed  to 
this  cause.  It  is  not  requisite  to  suppose  that  the  long  continuance 
of  this  action,  without  producing  suppuration  or  other  changes,  is 
an  argument  against  its  inflammatory  character.  The  inflamma- 
tion may  be,  like  those  in  fibrous  tissue,  of  long  continuance,  with- 
out inducing  any  other  effect  save  that  of  thickening  and  stiffness 
by  effusion  of  lymph. 

One  of  the  most  painful  and  least  managable  forms  of  nerve-ach 
is  that  which  is  produced  by  previous  disease  either  of  a bone  or  its 
periosteal  covering.  Chronic  periosteal  inflammation,  for  instance, 
attacks  the  bones  of  the  face,  and  affects  some  one  of  the  foramina, 
through  which  a nervous  chord  emerges.  The  periosteum  becomes 
thickened  as  the  periosteal  disease  proceeds ; the  bone  itself  is  af- 
fected, and  exostosis  is  formed.  This  tumour  compresses  the  nerve 
and  its  covering,  which  are  also  perhaps  inflamed ; and  if  the  newly 
formed  bone  is  sharp,  rough,  or  spicular,  by  lacerating  and  stretch- 
ing the  nerve,  it  causes  to  the  patient  acute  pain  and  much  suffering. 

Neuritis  should  be  distinguished  from  Neurilemmia,  though  often 
they  are  associated  and  consequently  cannot  be  distinguished.  Jo- 
seph Frank,  nevertheless,  thinks  that  the  constancy  of  the  pain  in 
the  former,  and  its  occasional  remission  and  periodical  recurrence 
in  the  latter,  may  serve  to  distinguish  the  two  affections. 

An  idea  has  been  advanced  by  Reil,  that  general  inflammation 
of  the  neurilema  takes  place  in  typhus  fever,  and  is  the  pathologi- 
cal cause  of  that  disease.*  That  the  vessels  of  this  tissue  may  be 
gorged,  and  their  blood  poisoned  and  rendered  hurtfnl,  in  common 
with  those  of  every  other,  is  exceedingly  probable,  and  may  be  often 
the  case.  But  it  is  manifest  that  this  is  one  only  of  many  simulta- 
neous effects;  and  it  is  further  evident,  that  neither  observation  nor 
anatomical  inspection  can  justify  the  conclusion,  that  inflammation 
of  the  neurilema  is  the  pathological  cause  of  fever. 

2.  Neurilemmia  Chronica.  Inflammation  of  nervous  tissue  may 
terminate,  in  resolution;  2d,  in  effusion  of  lymph;  3(i,  in  ul- 
ceration ; or,  4ith,  it  may  induce  a low  chronic  action,  accompanied 
with  enlargement  of  the  nerve,  or  morbid  growth  by  deposition  of 
new  matter.  These  phenomena  are  most  distinctly  seen  in  the 
changes  which  follow  wounds  of  nerves.  In  this  case  effusion  of 
lymph  is  common,  and  is  not  unfrequently  succeeded  either  by  lo- 

* Fieberlehre,  Band.  IV.  p.  56. 


S82 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


cal  palsy,  or  by  a train  of  symptoms  similar  to  nerve-ache.  {Neu- 
ralgia.) 

Dr  Denmark  saw  a contused  wound  of  the  radial  nerve  produce 
neuralgic  symptoms  requiring  amputation.*  Charles  Bell  saw  the 
same  result  succeed  contusion  without  wound  in  the  popliteal  nerve, 
and  the  inflammation  occasioned  by  the  application  of  quicksilver  to 
the  same  nerve. f Mr  Wardrope  saw  neuralgic  symptoms  succeed 
a puncture  of  the  finger,  in  which  he  thinks  a nerve  was  injured  \\ 
and  in  another  instance  similar  effects  from  wound  of  the  thumb, 
in  which  a branch  of  the  radial  nerve  close  to  the  digital  artery  was 
punctured.§  In  venesection  it  sometimes  happens  when  the  cutane- 
our  nerves  are  pierced,  that  numbness  and  tetanic  stiflness,  with 
spasmodic  twitches,  are  felt  in  the  arm  or  fore-arm  for  some  time 
after.  These  symptoms  it  is  justifiable  to  ascribe  to  chronic  inflam- 
mation, with  thickening  and  induration  of  the  nerve. |1  (Denmark.) 
This  thickening  depends  partly  on  extreme  and  undue  distension 
of  the  neurilematic  vessels,  partly  on  exudation  of  lymph,  which 
proceeds  from  the  same  source. 

In  the  remarkable  case  described  by  Mr  Pearson,  in  which  he 
ascribes  severe  and  complicated  neuralgic  and  paralytic  symptoms 
to  ‘‘a  morbid  condition  of  the  nerves  distributed  to  the  extremity 
of  the  thumb, ”1T  this  morbid  condition  was  probably  chronic  inflam- 
mation of  some  part  of  their  neurilematic  covering. 

Patients  who  have  undergone  amputation  sometimes  complain  of 
acute  pain  in  a single  point  of  the  stump,  liable  to  aggravation 
when  touched,  and  spreading  up  the  limb  in  the  course  of  the  nerves. 
It  is  usual  to  ascribe  such  complaints  to  implication  of  the  nerve  in 
the  cicatrix ; but  it  is  more  likely  that  a minute  branch  has  been 
included  in  the  ligature  of  some  of  the  vessels.  In  such  circum- 
stances it  is  manifest  that  a cause  is  given  for  the  most  severe  and 
obstinate  form  of  neurilematic  inflammation.  Lastly,  I may  notice, 
that  to  the  same  head  is  to  be  referred  a painful  gnawing  sensation 
of  contraction  ascending  up  the  arm  from  the  finger,  which  I have 

* Medico-Chirurgical  Transactions,  Vol.  IV.  p.  48.  London,  1813. 

+ Surgical  Observations,  &c.  By  Charles  Bell.  London,  1816,  p.  440.  Case  of 
Baron  Driesen. 

;j:  Medico-Chirurgical  Transactions.  Lond.  Vol.  VIII.  p.  246. 

§ Medico-Chirurgical  Transactions,  Vol.  XII.  p.  205. 

II  “ The  nerve  was  found  thickened  to  twice  its  natural  diameter,  and  contracted.” — 
Transact.  Vol.  IV.  p.  SI. 

^ Account  of  Remarkable  Symptoms,  &c.  By  John  Pearson,  Esq.  &c.  Medico- 
Chirurg.  Trans.  Vol.  VIII.  p.  252. 


NERVOUS  TISSUE. 


383 


seen  follow  the  communication  of  the  inflammation  of  whitloe  to  one 
of  the  small  branches  of  the  radial  nerve. 

3.  Ulceration  of  nervous  tissue,  though  rare,  may  occur  either 
after  wound,  laceration,  or  contusion  of  a nerve,  as  in  the  case  of 
ligature,  or  in  consequence  of  an  ulcer  of  the  contiguous  parts 
spreading  to  the  nerve.  It  does  not  appear  to  occur  spontaneously 
after  inflammation. 

4.  Division  and  De-union;  Excision  or  Removal,  and  Reproduc- 
tion. When  a nerve  is  cut  across,  no  doubt  can  be  entertained 
that  it  is  again  reunited.  But  it  is  questionable  whether  it  is  re- 
united by  simple  adhesion,  by  the  growth  of  new  nerve,  or  by  the 
growth  of  new  matter  entirely  different.  The  latter  point  has  been 
a particular  subject  of  inquiry  to  many  anatomists  and  physiologists 
in  the  case  of  excision,  or  removal  of  portions  of  a nervous  trunk. 
Though  the  nerves  have  been  divided  by  many,  the  first  accurate 
experiments  made  with  a view  to  ascertain  their  reproductive  power 
were  performed  by  Cruikshank.  This  anatomist  found,  that,  when 
a portion  of  nerve  is  removed  by  incision,  its  place  is  supplied  by 
blood  and  lymph,  which  first  becomes  vascular  and  organized,  and 
is  afterwards  converted  into  a substance  of  the  same  colour  as 
nerve ; and  which,  though  not  fibrous,  he  regarded  as  nervous.* 
These  experiments  were  repeated  by  Fontana,  who,  after  much 
hesitation,  came  to  the  conclusion  that  nervous  matter  is  repro- 
duced ;f  by  Arnemann,  who  denied  that  the  new-formed  matter  is 
nerve  ; J by  Haighton,  who  inferred  that  this  substance  is  really  and 
truly  nerve  ;§  by  Baronio,|l  Michaelis,1f . and  Meyer,**  who  have 
arrived  nearly  at  the  same  general  result,  and  assert  that  nervous 
filaments  may  be  traced  through  the  ne\^;^atter  of  the  cicatrix. 

According  to  Arnemann,  who  describef^^  process  of  reunion 
particularly,  shortly  after  section,  the  end  of  the  upper  portion  of 
cut  nerve  inflames  and  swells,  forming  a grayish,  long,  and  hard 

* Experiments  on  the  Nerves,  particularly  on  their  Reproduction.  By  William 
Cruikshank,  F.  R.  S.  &c.  Phil.  Transactions,  1795.  Parti,  p.  177. 

•f-  Experiences  sur  la  Reproductions  des  Nerfs,  apud  Traite  sur  la  Venin  de  la  Vi- 
pere,  &c.  Par  Felix  Fontana.  Tom.  II.  Florence,  1781,  p.  177. 

J Ueher  die  Reproduction  der  Nerven.  Goettingen,  1786.  Versuche  Ueber  die 
Regeneration  der  Nerven.  Ibid.  1787. 

§ An  Experimental  Inquiry  on  the  Reproduction  of  Nerves.  By  John  Haighton 
M.  D.  Philosophical  Transact.  Lond.  1795.  Part  I.  p.  190. 

II  Memorie  de  Matematica  e Fisica,  Vol.  IV. 
f Fr.  Michaelis  Ueber  die  Regeneration  der  Nerven.  Cassel,  1786 
**  Meyer  apud  Reil  Archiv.  fiir  die  Physiologie,  II.  Band.  p.  449. 


384 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


knot ; the  end  of  the  lower  portion  undergoes  the  same  change,  but 
in  less  degree ; the  knotty  parts  unite ; and  the  substance  which 
thus  connects  the  cut  portions  of  nerve,  though  it  continues  hard 
and  large,  is  considered  as  either  nervous  matter,  or  as  containing 
a considerable  portion  of  that  substance,  for  the  sensations  and  mo- 
tions of  the  parts  are  in  most  cases  restored  shortly  after  union. 

This  ])rocess,  according  to  Bichat,  therefore,  consists  of  four 
stages.  Isf,  After  incision  the  cut  ends  inflame,  and  the  capillaries 
of  the  divided  portions  effuse  coagulating  or  organizable  lymph, 
which  is  penetrated  with  blood-vessels.  2d,  This  effusion,  which 
takes  place  chiefly  from  the  neurilema,  forms  a sort  of  cellular 
tissue,  in  which  nervous  matter  is  afterwards  deposited.  This  cel- 
lular tissue,  and  the  new  matter  in  general,  is  in  quantity  according 
to  the  spaces  to  be  filled  up.  If  it  be  large,  the  new  matter  is  aug- 
mented by  successive  effusion  and  granulation ; and  when  small, 
the  connection  by  deposition  appears  to  be  very  speedily  eflfected.  ?>d. 
The  adhesion  of  the  individual  granulating  bodies  and  consolidation 
of  the  part.  Ath,  The  deposition  or  exhalation  of  nervous  substance 
in  the  new  matter.*  Is  this,  which  is  said  to  be  the  last  stage  of 
the  process,  not  co-existent  and  simultaneous  with  the  effusion  of 
new  matter  in  general  ? What  are  the  proofs  which  show  that  the 
proper  nervous  matter  is  last  deposited? 

When  a nerve  has  been  divided  under  circumstances  which  pre- 
vent it  from  uniting  in  any  manner  with  its  detached  segment,  as 
in  amputation,  the  extremity  enlarges  and  becomes  vascular,  from 
the  neurilematic  vessels  assuming  the  inflammatory  action ; blood 
and  lymph  are  effused  both  from  the  cut  extremity  and  into  the  in- 
terstices of  the  neurilematic  canals ; more  or  less  adhesion  is  con- 
tracted with  the  contiguous  textures ; and  when  the  active  state  of 
this  process  has  subsided,  a hard  knotty  tubercle  is  left  in  the  site 
of  the  cut  extremity.  This  tubercle  is  at  first  rendered  vascular, 
afterwards  grayish,  solid,  and  so  firm  that  the  knife  may  be  blunted 
in  dividing  it.  (Arnemann.)  The  changes  now  mentioned  I have 
often  traced  in  the  surface  of  stumps  during  healing.  The  size  and 
shape  of  the  tubercle  vary  according  to  circumstances  not  well  as- 
certained. When  situate  not  exactly  at  the  extremity,  as  observed 
by  Van  Horne, f it  merely  shows  that  the  inflammatory  process  had 
spread  farther  up  the  nerve  than  usual. 

• Anat.  Gen.  Tom.  I.  Art.  iii.  sect.  3,  p.  176. 

-|-  De  iis  qu£e  in  partibus  membri  amputatione  vulneratis  notanda  sunt.  Lugduni 
Batav.  1803. 


NERVOUS  TISSUE, 


385 


It  was  at  one  time  supposed  that  the  morbid  growth  called  blood- 
like  fungus  (fungus  hcematodes ) was  peculiar  to  the  nervous  tissue. 
This  idea  is  now  known  to  be  incorrect ; and  it  appears  that  there 
is  no  process  of  disorganization  peculiar  to  nerve,  and  not  occurring 
in  other  textures. 

Nervous  texture  is  sometimes  unnaturally  soft ; as  in  dropsy, 
fatal  hemorrhages,  and  diseases  of  long  wasting.  (Autenrieth.)  Is 
it  ever  unusually  soft  primarily,  and  without  being  the  result  of 
another  disease?  It  undergoes  mollescence  (ramollissement)  in 
consequence  of  mechanical  injury ; but  it  is  exceedingly  doubtful 
if  this  takes  place  spontaneously. 

4.  Local  forms  of  palsy,  that  is,  loss  of  mobility  in  an  order  of 
muscles,  or  in  a limb,  is  a common  result  of  injury  done  to  a nerve 
or  nerves.  The  effect  of  such  injury  is  in  general  to  produce  in- 
flammation or  extravasation,  and  subsequent  destruction  of  the 
proper  nervous  matter.  It  becomes  soft,  pulpy,  and  disorganized. 
In  this  state  the  nerve  is  no  longer  fit  to  perform  its  usual  func- 
tions, and  it  loses  the  influence  which  it  possessed  over  the  muscles 
to  which  it  is  distributed.  In  the  course  of  this  process  irregular 
motions,  or  what  are  termed  spasms,  not  unfrequently  occur. 

5.  Tetanus. — Punctured  or  lacerated  wounds  of  nervous  tissue  may 
be  followed  by  tonic  spasms,  {tetanus,)  or  by  convulsive  motions  in 
general.  It  is  uncertain  in  this  case  whether  the  irregular  motions 
depend  on  injury  of  the  nerve,  or  its  neurilematic  sheath. 

The  following  facts  I have  ascertained  in  several  cases  in  which 
tetanus  followed  fracture  of  the  fingers  with  contused  wounds  of 
the  soft  parts. 

In  two  cases  I may  mention,  in  which  the  injuries  were  very  si- 
milar, viz.  fracture  of  the  middle  phalanges  of  the  finger,  the  symp- 
toms of  tetanus  came  on  about  three  weeks  after  the  infliction  of 
the  injury,  and  proceeded  in  the  course  of  a few  days  to  the  fatal 
termination.  In  the  first  case,  the  body  of  a cart,  which  had  been 
emptied,  and  for  this  purpose  had  been  raised,  fell  on  the  hand  of 
the  person,  and  caused  fracture  of  the  bones  of  the  finger  with  con- 
tusion. In  the  second  case,  the  mast  of  a boat  which  had  been 
raised,  and  was  standing  not  securely,  fell  on  the  hand  of  the  per- 
son, and  in  like  manner  produced  fracture  of  the  phalanges  of  the 
thumb. 

In  both  cases  the  nerve-coat  connected  with  the  injured  part  was 
reddened,  vascular,  and  injected,  and  manifestly  thickened,  while  the 
nervous  matter  of  the  nerve  was  reddened,  swelled,  and  softened. 

B b 


386 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


In  the  first  of  these  cases,  which  took  place  in  the  person  of  a 
young  raan,  who  had  been  brought  from  Musselburgh  to  the  Edin- 
burgh Royal  Infirmary,  I examined  the  whole  spinal  chord  with 
care.  I found  it  quite  sound,  except  in  the  cervical  portion,  where 
the  envelopes  were  reddened,  and  had  evidently  been  the  seat  of 
inflammatory  injection.  Beneath  these  envelopes,  the  spinal  chord 
in  the  cervical  portion  was  reddened  and  softened  for  the  space  of 
between  one  inch  and  a-half  and  two  inches.  So  far  as  I could 
determine,  this  was  the  point  which  gives  origin  to,  or  is  connected 
with  those  branches  of  the  cervical  nerves  which  proceed  to  and 
chiefly  form  the  brachial  plexus. 

In  this  case,  therefore,  I inferred,  that  the  injury  done  the 
finger,  and  the  subsequent  inflammation,  especially  of  the  digital 
nerve  and  its  nerve-coat,  had  been  reflected,  as  it  were,  to  the  spinal 
origins  of  these  nerves,  and  thus  induced  inflammation  and  irritation 
of  the  spinal  marrow,  then  softening ; and  that  these  were  the  efii' 
cient  causes  of  the  tetanic  symptoms  and  their  fatal  termination. 

In  the  second  case,  in  which  the  patient  died  under  the  care  of 
my  friend.  Dr  Paterson  of  Leith,  and  by  whose  attention  I was 
present  at  the  inspection,  we  found  the  contused  ends  of  the  nerve 
red  and  softened,  and  its  tunic  in  like  manner  red,  injected,  and 
thickened ; and  in  the  same  manner,  on  inspecting  the  spinal  mar- 
row, a portion  of  that  organ  in  the  cervical  region  not  less  than 
two  inches  in  length,  very  distinctly  reddened  and  softened,  indeed, 
quite  creamy,  while  the  rest  of  the  chord  was  firm  and  of  normal 
consistence. 

The  spot  thus  affected  with  softening  corresponded  very  accu- 
rately with  the  origins  or  spinal  connections  of  the  cervical  nerves 
which  contribute  to  form  the  brachial  plexus. 

It  is  proper  to  say,  that  I had  mentioned  to  Dr  Paterson  what 
I expected  to  find  in  the  spinal  marrow,  and  my  reasons  for  this 
expectation  as  founded  on  the  facts  of  the  previous  case.  The  dis- 
covery of  the  connection  between  the  inflamed  nerve  and  the  re- 
flected irritation  and  inflammatory  softening  of  the  spinal  chord  was 
not  the  effect  of  accident. 

I have  repeatedly  seen  the  nerve  or  nerves  of  parts  injured  and 
contused  in  tetanic  cases,  presenting  redness,  vascularity,  thickening 
of  the  neurilemma,  and  softening  of  the  nerve.  But  I have  not  had 
opportunities  of  examining  the  spinal  chord  in  any  other  case. 

I think,  nevertheless,  that  it  is  reasonable  to  infer,  that  the  irrita- 
tion is  propagated  from  the  injured  parts  in  the  reflex  direction  to  the 

3 


NERVOUS  TISSUE. 


387 


spinal  connections  of  the  nerves  ; that  there  it  is  followed  hy  another 
irritation  and  hy  inflammation  of  the  spinal  marrow ; and  that  the  last 
is  the  cause  of  the  tetanic  symptoms.  This  further  seems  most  pro- 
bable when  we  consider  that  some  time  always  elapses  between  the 
date  of  the  infliction  of  the  injury,  and  that  of  the  development  of 
the  tetanic  symptoms ; that  is  to  say,  the  establishment  of  the  in- 
flammatory irritation  of  the  spinal  marrow. 

At  the  same  time,  to  render  this  theory  of  the  cause  of  tetanus 
complete,  it  would  he  requisite  to  inspect  in  the  same  manner  cases 
in  which  fractures  or  other  injuries  of  the  lower  extremities  had  been 
followed  by  tetanus.  This  I have  not  had  opportunities  of  doing. 

Traumatic  tetanus  is  almost  invariably  a fatal  disease  ; and  the 
reason  of  this  is,  that  it  follows  or  is  caused  by  a severe  lesion  of 
the  spinal  chord  at  parts  essential  to  the  continuance  of  life. 

Q.  Tumours.  A.  (iVewrowzaof  Odier.)  Tumours  of  various  size  and 
structure  have  been  found  in  nervous  trunks.  These  may  be  either 
common  to  nerve  with  other  tissues,  or  proper.* * * §  Of  the  former  an 
example  is  given  in  the  encysted  tumour  (hygroma)  which  Chesel- 
dent  found  in  the  centre  of  the  cubital  (iilnar)  nerve.  Of  that  met 
with  by  Grooch  in  the  axillary  nerve,  the  account  is  not  so  distinct,  j; 
Sir  Everard  Home  mentions  a tumour  removed  from  the  middle  of 
the  right  arm  hy  John  Hunter,  and  in  which  the  musculo-cutaneous 
nerve  was  found  imbedded,  divided  into  two  portions,  each  much 
flattened.  § This  tumour  appears  to  have  originated  in  the  neurilem. 
In  another  instance  Sir  E.  Home  removed  a tumour,  in  which  one 
of  the  large  nerves  of  the  axillary  plexus  was  encased. 

Lastly^  Odier  describes,  under  the  name  of  neuroma,  in  the  per- 
son of  a member  of  his  own  family,  an  instance  of  tumour  in  the 
radial  nerve,  in  which  its  component  threads  were  separated  from 
each  other  in  the  manner  of  a fan,  or  like  the  ribs  of  a melon, 

* It  is  singiilar  to  remark  with  how  little  precision  pathological  writers  speak  of  these 
tumours.  Odier  compares  the  one  mentioned  by  Cheselden  to  a firm  one  noticed  by 
Gooch,  and  to  the  yellow-whitish  tumour  which  he  met  in  the  radial  nerve  of  a rela- 
tive. Meckel  also  refers  to  Cheselden ’s  case  in  speaking  of  tumours,  considerably  hard, 
roundish,  yellow-whitish,  of  fibrous  structure,  and  approacliing  to  fibro-cartilage.  The 
case  of  Cheselden  should  have  been  careful!}’  distinguished  from  the  tumours  intended 
to  exemplify  this  description.  For  that  surgeon  states  specifically,  that  “ it  was  of  the 
cystic  kind,  but  contained  a transparent  jeUy.”  It  was  in  truth  an  instance  of 
hygroma,  and,  as  I have  stated  in  the  text,  it  was  common  to  the  nervous  and  other 
tissues. 

t The  Anatomy  of  the  Human  Body,  p.  256.  London,  1778  and  1781.  12th  Edit. 

J Cases  and  Practical  Remarks  in  Surgery,  Vol.  II. 

§ Trans,  of  a Society,  &c.  Vol.  II.  p.  152.  An  Account,  &c. 


388 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


while  the  centre  was  filled  with  white  and  yellow  matter,  effused  in 
the  intervals  of  an  infinite  number  of  transparent  vessels,  mutually 
interlacing.*  Examples  of  similar  tumours  are  mentioned  by 
Marandel,t  Neumann, :j:  Von  Siebold,§  Spangenberg,|l  Alexan- 
der,1f  Mojon,  and  Covercelli.** 

Of  the  cases  recorded  by  Von  Siebold,  one  occurred  in  the  per- 
son of  an  aged  female  with  varicose  veins  of  both  legs  and  feet. 
Two  small  nervous  tumours  were  situate  near  each  other  at  the 
instep,  between  the  ankles.  They  caused  severe  pains,  which  were 
alleviated  neither  by  narcotics  nor  stimulants.  His  father  applied 
caustic,  and  the  disease  disappeared,  but  soon  returned.  Von 
Siebold  himself  again  employed  caustic  more  efficaciously,  and  ex- 
tirpated the  disease. 

The  case  recorded  by  Neumann  took  place  in  an  old  man  of  70, 
on  tbe  middle  and  lower  part  of  whose  fore-arm  a tumour  as  large 
as  a pea,  very  painful  on  being  touched  or  sustaining  the  slight- 
est pressure,  had  continued  for  thirty  years.  It  was  ascribed  to 
a violent  blow  received  on  the  arm.  The  skin  covering  it  was 
healthy  and  movable,  though  the  tumour  itself  was  immovable, 
in  consequence  of  attachments  to  muscles.  Neumann  recommend- 
ed excision.  But  the  surgeon  was  afraid,  lest,  in  dividing  the  nerve 
he  should  injure  the  artery,  and  be  attempted  to  remove  it  by  excit- 
ing suppuration  produced  by.  the  application  of  caustic.  Meanwhile 
the  patient  was  destroyed  by  apoplexy. 

Of  the  cases  described  by  Spangenberg  and  Alexander,  two 
occurred  to  Dubois.  One  as  large  as  a walnut,  was  situate  on 
the  patella.  Another,  as  large  as  a middle-sized  melon,  was  con- 
nected with  the  median  nerve  of  the  right  arm.  It  was  slightly 
movable  without  discoloration  of  the  skin.  Both  were  extirpated. 

The  great  evil  of  these  tumours  is,  that  from  their  relations 
they  cause  much  pain.  Thus  Nicod  states,  that  in  1816  he  removed 
from  the  chest  of  a female  aged  40,  a lenticular  tumour  from  six 
to  seven  lines  in  diameter,  movable  in  the  subcutaneous  cellular 
tissue,  apparently  covered  by  the  skin,  w^hich  was  attenuated  so 

* Manuel  de  Medecine  Pratique,  &c.  Par  Louis  Odier,  Doct.  et  Prof,  a Paris  et 
Geneve,  1811.  Cl.  IV.  Ord.  v.  17,  p.  362. 

t Bulletin  apud  Journal  de  Medecine  continue,  Vol.  XI. 

$ In  Von  Siebold  Sammlung  Chirurg.  Beobachtungen. 

§ Von  Siebold  I.  Band.  p.  80,  82. 

II  In  Horn  Archiv.  V.  Band,  2 Heft,  St.  2.  306. 

H F.  S.  Alexander,  Dissertatio  de  Tumoribus  Nervorrun.  Lugd.  B.  1810. 

**  Chiron,  Band  1.  St.  3|  and  Memorie  della  Societate  di  Genova. 


NERYOUS  TISSUE. 


389 


much  as  to  present  a faint  brownish  tint.  This  colour,  with  the 
severe  pains  which  totally  prevented  sleep  for  months,  made  it  be 
taken  by  several  medical  men  for  cancerous.  It  was  encysted,  and 
its  removal  was  followed  by  sound  sleep,  which  lasted  that  day  and 
the  ensuing  night  and  day.* 

Some  years  ago  I saw,  in  the  arm  of  a woman  about  thirty,  an 
oblong  pyriform  hard  body,  extending  along  the  inner  margin  of 
the  biceps  flexor,  in  the  site  of  the  brachial  vessels  and  nerves,  to  the 
anterior  tuberosity  of  the  humerus.  It  was  attended  with  prickling 
pain,  and  alternating  with  numbness  of  the  arm,  fore-arm,  and  fin- 
gers. From  these  symptoms  (Home,)  the  absence  of  pulsation  and 
its  situation,  no  doubt  could  be  entertained  that  it  implicated  the 
brachial  nerve.  The  woman  refused,  however,  to  submit  to  have 
it  removed  ; and  I have  not  since  heard  of  her.  The  evidence  of 
dissection  as  to  its  precise  nature  is  therefore  still  wanting. 

It  is  not  easy  to  determine  which  of  these  tumours  are  to  be  re- 
garded as  common,  or  proper  to  the  nervous  chord  or  the  neurile- 
matic  tissue.  It  is  manifest  that  the  case  of  Cheselden,  and  perhaps 
that  of  Gooch,  and  the  second  one  of  Home,  were  common.  That 
of  Odier,  and  the  first  of  Home,  appear  to  have  been  seated  either 
in  the  neurilema,  or.  its  cellular  tissue,  and  probably  consisted  in 
deposition  of  new  matter  in  the  interstices  of  the  neurilematic 
canals.  In  the  former  case  the  filaments  of  the  nerve  are  more  or 
less  expanded  and  separated.  In  the  latter  they  pass  through  the 
body  of  the  tumour  in  a mass. 

The  anatomical  structure  of  these  tumours  is  probably  most  fully 
illustrated  by  a case  recorded  by  Alexander,  in  which  a tumour  as 
large  as  a hen’s  egg  was  removed  from  the  left  arm  of  a soldier  of 
19  years  of  age,  and  in  whom  it  was  believed  to  be  seated  in  the 
ulnar  nerve.  In  this  case  the  neurilema  formed  an  external  cap- 
sule. The  ulnar  nerve  divided  longitudinally  for  nearly  half  an 
inch  above  the  tumour  was  found  sound,  to  the  point  where  it 
was  dilated ; as  it  was  also  sound  below  the  tumour,  where  in 
like  manner  about  half  an  inch  of  the  nerve  was  removed  by  the 
incisions,  which  embraced  the  longitudinal  extent  of  four  inches. 

The  colour  of  the  tumour  was  the  same  as  that  of  the  nerve, 
though  more  brilliant.  The  naked  eye  distinguished  longitudinal 
fibres,  invested  by  some  transverse  fibres.  It  was  hard  to  the 
touch,  elastic,  and  it  was  then  observed  to  enclose  a. liquid. 

When  divided  longitudinally,  the  external  wall  was  more  resist- 

* Nouveau  Journal  de  Medecine,  Not.  1818. 


300 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


ing  than  that  of  the  nerve,  and  of  a consistence  about  tendinous,  but 
not  cartilaginous.  By  a small  opening  there  escaped  a limpid  fluid 
similar  to  serum,  and  coagulating ; and  when  this  was  forced  out 
by  the  elasticity  of  the  external  tunic,  the  volume  of  the  tumour  di- 
minished one-third. 

The  external  wall  or  neurileraatic  tunic  of  the  tumour  was  hard 
and  thicker  than  in  the  sound  state  of  the  nerve.  At  the  middle 
of  the  tumour  this  capsule  was  expanded  into  a thin  though  consis- 
tent membrane.  The  inner  surface  of  the  capsule,  when  examin- 
ed by  a lens,  presented  fine  parallel  fibres. 

The  cavity  formed  within  the  neurilema  was  lined  all  over  by  a 
dense  pulpy  plate ; leaving  in  the  centre  of  the  tumour  an  oblong 
cavity  like  that  of  an  egg,  in  which  was  contained  the  sero-albumi- 
nous  fluid. 

In  the  interior  of  the  tumour,  the  pulp,  differing  from  that  in  the 
sound  state,  presented  a morbid  aspect,  well  marked,  was  half  an  inch 
thick,  presented  no  straight  parallel  fibres,  but  a mass  of  numerous 
small  round  bodies,  firm  and  covered  by  an  envelope,  similar  to  fibres 
twisted  in  the  spiral  direction,  aggregated,  resembling  those  which 
Fontana  recognized,  by  the  aid  of  the  microscope,  in  the  medullary 
matter  of  the  nerves,  and  in  the  cortical  matter  of  the  brain. 

In  another  case  recorded  by  Alexander,  in  which  a very  painful 
neuromatic  tumour  was  extirpated  by  Reich  from  the  right  elbow  of 
a gentleman  of  44,  in  whom  it  had  been  growing  since  the  eleventh 
year  of  his  age ; though  it  was  not  so  easy  to  ascertain  the  anato- 
mical characters,  it  was  observed,  that  the  nervous  fibrils  were  en- 
larged, and  filled  with  serous  fluid  at  the  place  of  the  tumour  ; that 
their  neurilema  was  indurated  and  contained  a fluid  ; and  that  in 
this  investment  were  seen  firm  tendinous  fibres.* 

Cruveilhier  represents  a spheroidal  tumour  the  size  of  a small 
nut,  which  was  formed  in  the  substance  of  the  radial  nerve,  where 
it  passes  between  the  supinator  longus  and  the  brachiaeus  anticus. 
The  long  supinator  was  thinned,  and  thrown  outward  by  the  tumour 
on  which  it  was  moulded.  The  substance  of  the  nerve  seemed  in- 
terrupted at  the  site  of  the  tumour ; yet  most  of  its  filaments  were 
continuous  though  separated,  and  could  be  traced,  some  before  and 
others  behind  the  tumour.  Several  were  lost  in  the  fibrous  cover- 
ing ; none  traversed  the  tumour.  Cruveilhier  considers  this  a carci- 
nomatous tumour,  and  the  effect  of  secondary  cancerous  infection. f 
If  that  view  be  correct,  it  should  not  be  regarded  as  neuroma. 

-|-  Livraison  xxxv. 


* Observatio  secuiida. 


NERVOUS  TISSUE. 


391 


The  gangliophorous  or  organic  nerves,  as  well  as  those  of  animal 
life,  are  liable  to  the  formation  of  tumours.  Cruveilhier  represents 
in  the  cervical  ganglions  of  the  great  sympathetic  oblong  spheroidal 
tumours  of  fibrous  character,  which  had  been  formed  in  these  gang- 
lions. These  tumours  he  considers  as  instances  of  the  fibrous  de- 
velopment with  hypertrophy  ; a statement  from  which  little  is  to  be 
learned.*  It  is  certain  that  the  ganglions  are  much  enlarged,  and 
that  their  substance  is  indurated  ; that  these  swellings  are  contained 
within  a tumour  or  capsule  of  some  thickness  and  firmness ; and 
that  the  substance  enclosed  presents  a fibrous  arrangement,  yet 
with  some  remains  of  the  original  matter  of  the  ganglion.  They 
seem,  indeed,  to  be  examples  of  neuroma. 

On  the  whole,  it  seems  probable  that  the  neuromatic  tumour  is  not 
in  all  cases  the  same  ; that  sometimes  it  is  the  result  of  sero-albumi- 
nous  fluid  eflfused  interstitially  in  the  texture  of  the  nerve  at  one 
point  in  consequence  of  chronic  inflammation,  and  afterwards  coa- 
gulating ; that  sometimes,  from  the  operation  of  the  same  cause,  a 
cavity  or  cavities  are  formed,  containing  sero-albuminous  fluid  un- 
coagulated ; that  the  nervous  fibrils  are  seldom  destroyed,  but  are 
often  separated  and  stretched,  irritated,  and  compressed ; and  that 
never  in  the  proper  neuroma  is  new  or  heterologous  matter  deposited. 

B.  Neuromation,  (Nsi;5o,aar/ov.)  (Subcutaneous  tubercle  of  Mr 
Wood.)  By  this  name  may  be  distinguished  those  pisiform  tumours 
or  hard  tubercles  which  form  beneath  the  skin,  and  of  which  I had 
already  occasion  to  speak  when  enumerating  the  morbid  states  of 
the  filamentous  tissue.  I then  had  occasion  to  remark,  that  there 
is  strong  reason  for  thinking  that  this  painful  disease  consists  in  the 
hard  body  being  seated  in  some  of  the  nervous  twigs  beneath  the 
skin.  I am  now  to  advance  such  evidence  as  may  show,  that  little 
doubt  can  be  entertained  that  this  is  the  true  pathology  of  the  sub- 
cutaneous tubercle. 

Valsalva  had  early  observed  an  instance  of  a small  hard  tumour 
at  the  ankle  of  a lady,  in  whom  it  continued  from  the  16  th  year, 
and  gave  rise  to  pain  so  intense,  that  she  would  herself  have  at- 
tempted extirpation,  had  she  not  been  prevented  by  her  domestics. 
It  was  removed  and  the  pain  returned  no  more. 

Hard,  painful,  pisiform  tumours  beneath  the  skin  are  next  men- 
tioned by  Cheselden,  who  met  with  three  cases  in  which  he  employ- 
ed excision,  without  being  aware  that  they  might  be  seated  in  the 
nerves  or  their  coverings.!  The  next  recorded  case  is  that  given  by 

* Liviaison  I.  Planche  iiiieme. 

-j-  Anatomy  of  the  Human  Body.  By  William  Cheselden,  p.  136. 


392 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Dr  Short,  who  in  1720  found  in  the  leg  one  causing  epilepsy,  and 
which  he  removed  by  excision.*  Camper  is,  so  far  as  I am  aware,  the 
first  anatomist,  who  remarks  the  occasional  occurrence  of  minute 
hard  tubercles,  not  larger  than  a pea,  in  the  cutaneous  nerves; 
where  he  represents  them  as  giving  rise  to  excruciating  darting 
pains  night  and  day,  admitting  of  no  alleviation  from  external  re- 
medies. Of  this  kind  he  met  with  one  in  the  musculo-cutaneous 
nerve  of  a woman  at  Franequer,  and  another  in  the  knee  of  a wo- 
man at  Amsterdam.  Both  he  removed  by  excision,  and  found 
them  white  internally,  of  gristly  hardness,  elastic,  and  seated  with- 
in the  neurilema.f 

The  next  notice  of  this  disease  is  by  Dr  Bisset,  who  observed  it 
in  the  form  of  an  irregularly-oval  tumour,  the  size  of  a filbert,  on 
the  outside  of  the  left  leg,  six  inches  above  the  outer  ancle,  also  in 
a woman  of  twenty-nine  years.f  Soon  after  it  was  observed  by 
Mr  Pearson  in  the  subcutaneous  nerve  which  accompanies  the  sa- 
phmna  vein,  in  the  leg  of  a woman  of  fifty-one ; in  the  back  of  the 
leg,  near  the  Undo  Achillis  ; and  at  the  bend  of  the  arm,  near  the 
median  vein,§  in  a young  married  woman.  Since  this  time  the  dis- 
ease was  fully  and  accurately  described  by  Mr  William  Wood  of 
this  city  ; I|  and  occasional  cases  have  been  published  by  other  au- 
thors.^ 

Mr  Wood  questions  the  justice  of  the  opinion  of  Camper,  that 
the  tubercle  is  seated  in  the  nerve-coat,  or  is  a nervous  tumour ; 
and  thinks  that  it  is  a distinct  or  peculiar  species  of  tumour,  situate 
in  the  subcutaneous  cellular  membrane.  It  may  not  perhaps  be  pos- 
sible to  prove  that  every  little  subcutaneous  tubercle  is  of  this  descrip- 
tion. But  the  observations  of  the  authors  above  mentioned,  and  those 
of  A.  Petit,**  Tissot,  Lassus,  Jacopi,ft  Monteggia,||  and  Alexander, 

* An  Epilepsy  from  an  Uncommon  Cause.  By  Ur  Thomas  Short,  Physician  at 
Sheffield.  Medical  Essays  and  Observations,  Vol.  IV.  art.  xxvii.  p.  416.  Edinburgh, 
1738.  A tumour  the  size  of  a pea  in  the  posterior  tibial  nerve,  near  the  lower  end  of 
gastrdcnemii- 

-j-  Petri  Camper  Demonstrationum  Anatomico-Pathologicarum,  Lib.  i.  Caput  2.  § 5^ 
p.  11.  Lugduni  Bat.  Folio  Imp. 

J Memoirs  of  the  Medical  Society  of  London,  Vol.  III.  p.  58.  Case  of  Irritable 
Tumour.  By  C.  Bisset,  M.  D.  &c.  London,  1792. 

§ Medical  Facts  and  Observations,  Vol.  VI.  p.  96.  Account,  &c. 

II  Medical  and  Surgical  Journal,  Vol.  VIII.  p.  283,  429.  Edinburgh  Medico-Chi- 
rurgical  Transactions,  Vol.  III.  Edinburgh,  1829. 

Ibid.  Vol.  XL  XVII.  XVIII. 

**  Essai  sur  la  Medecine,  &c.  A Lyon,  1806. 

tt  Prospetto  della  Scuola  di  Chirurgia  Pratica,  &c.  Vol.  I.  cap.  9.  Milano,  1813. 

Istituz.  Chirur.  Vol.  II.  Capo  xiv.  p.  197.  Milano,  1813. 


NERVOUS  TISSUE. 


393 


show  manifestly  that  the  nerves  are  liable  to  tubercles  of  this  kind. 
The  proofs,  in  short,  which  may  be  adduced  in  favour  of  this  idea, 
are  the  following.  1 . In  many  instances  of  subcutaneous  tubercle 
the  lenticular  body  has  been  formed  in  the  substance  or  coat  of  a 
nerve.  (Short,  Camper,  Bisset,  A.  Petit,  Tissot,  Lassus,  Jacopi,  &c.) 
2.  In  the  majority  of  cases  the  tubercle  can  be  traced  distinctly  to 
the  branch,  twig,  or  filament  of  a subcutaneous  nerve.  3.  The  pain- 
ful sensation  of  which  it  is  the  seat,  though  severe  and  constant,  is 
always  aggravated  by  handling  or  pressing  the  tumour,  and  may  be 
always  traced  along  nervous  branches. 

In  the  cases  in  which  the  neuromatic  tubercle  has  been  dissected, 
it  has  been  found  hard,  cartilaginous,  and  slightly  vascular.  It 
seems  in  general  to  consist  in  morbid  change  of  the  neurilema,  by 
deposition  of  albuminous  matter  in  the  neurilematic  interstices. 
(Jacopi.)  It  is  much  more  frequent  in  women  than  in  men,  in  the 
proportion  nearly  of  from  seven  to  one,  and  from  ten  to  one. 
Monteggia  states  that  he  found  the  entire  nervous  system  occupied 
with  numerous  (centinaia,)  neuromatic  tubercles,  which  would  in- 
dicate, as  he  observes,  in  some  instances  a neuromatic  diathesis.* 
The  cause  of  their  formation  is  not  known ; but  from  the  effects  of 
ligature,  division,  and  other  injury,  it  may  be  in  some  manner  con- 
ceived. 

It  is  important  to  observe,  that  in  both  classes  of  cases,  the  pre- 
sence of  these  tumours  gives  rise  to  various  remarkable  effects. 
Thus  they  may,  by  the  irritation  which  they  cause  in  the  nerve, 
induce  not  only  intense  pain,  but  give  rise  to  epileptic  motions. 
This  is  shown  by  the  remarkable  case  given  by  Dr  Short  so  far 
back  as  in  1720,j  by  the  cases  recorded  by  Mojon  and  Covercelli,^ 
and  by  one  mentioned  by  Portal.§  Is  it  not  probable  that,  of  the 
cases  described  as  preceded  by  aura  epileptica  several  belong  to 
this  head,  and  are  cases  in  which  there  is  in  a nerve  either  a tubercle 
or  some  similar  source  of  irritation  ? 

In  other  instances,  these  tumours  are  attended  with  anomalous 
and  sometimes  severe  nervous  symptoms.  Pain  and  prickling  or 
the  feeling  of  the  electric  shock  from  the  tumour  along  the  limb. 

* Istituzione  Chirurgiche,  Vol.  II.  p.  197. 

An  Epilepsy,  &c.  Med.  Essays  and  Observ.  VoL  IV.  p.  416. 

J Memorie  della  Socjetate  di  Genova.  Und  Von  Siebold,  Chiron,  Band  I.  St.  3, 
where  the  Memoires  of  Mojon  and  Covercelli  are  translated. 

§ Anatomie  Medicale.  Par  A.  Portal,  Tome  IV.  p.  246.  A body  like  a hard  corn 
near  the  articulation  of  the  first  with  the  second  phalanx  on  the  palmar  surface  of 
the  thumb. 


394 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Occasionally  spasmodic  motions  take  place ; and  in  certain  cases 
the  functions  of  the  part  are  destroyed.  Thus  a man  of  36  years 
of  age  lost  his  sight  in  consequence  of  the  formation  of  a neuromatic 
tumour  in  the  optic  nerve,  (Sedillot,)  a little  larger  than  a hemp- 
seed.*  In  a man  of  60,  who  suffered  from  symptoms  of  asthma,  a 
tubercle  the  size  of  a pea  was  found  in  the  right  diaphragmatic  nerve. f 

The  causes  of  neuroma  and  neuromation  are  little  known.  In 
several  of  the  cases,  the  formation  of  the  tumour  was  preceded  by 
violence  or  injury.  In  others  it  arose  spontaneously.  The  circum- 
stances of  the  following  case  show  the  effect  of  chronic  inflamma- 
tion arising  from  causes  operating  on  the  system  at  large,  and  pro- 
bably on  the  digestive  functions. 

A student  in  medicine,  an  internal  pupil  at  the  Hotel  Dieu  of 
Angers,  occupying  an  apartment  situate  several  feet  below  the  level 
of  the  court,  and  sleeping  in  a recess  formed  in  the  substance  of 
the  wall  of  the  hospital,  suffered,  at  the  end  of  some  months’  abode 
in  this  unhealthy  place,  an  attack  of  arthritis  in  the  great  toe ; and, 
shortly  after,  there  was  formed,  beneath  the  skin  covering  the  in- 
ternal saphena  vein  and  nerve  in  the  leg,  a hard  tumour,  of  the 
size  of  a grain  of  wheat,  and,  whenever  it  was  touched  by  the  pa- 
tient, either  in  dressing  or  undressing,  or  under  any  other  circum- 
stances, eaused  pain,  shooting  like  an  electric  shock  upon  the  foot, 
in  the  direction  of  the  ramifications  of  the  nerve. 

Having  obtained  from  the  administrators  of  the  hospital  another 
apartment,  he  was  at  the  end  of  some  months  cured  of  the  neural- 
gia and  the  neuromatic  tubercle.  The  same  individual,  when  some 
years  afterwards  at  Paris,  had  under  the  chin  a little  boil,  the  ci- 
catrix of  which  continued  for  several  months  the  seat  of  acute  pain, 
caused  by  the  friction  of  the  razor,  and  which  spread  in  a radiating 
direction  over  the  neck  and  chest.  The  subject  of  this  case  was  the 
late  M.  Beclard.J 

7.  Considerable  wasting  and  shrinking  were  seen  in  the  optic 
nerves  by  Spigelius,  Riolan,  Rolfinck,  Morgagni,  Santorini,  and 
Benninger ; and  complete  destruction  in  the  olfacient  nerves  by 
Falkenburg.  These  changes,  which  take  place  generally  at  the 
cerebral  end  of  the  nerve,  are  accompanied  with  diminution  or  loss 
of  function. 

* Journal  de  Medecine,  Tome  L. 

•j-  Dissertation  sur  les  Affections  Locales  des  Nerfs.  Par  Pierre  Jules  Descot,  D.  M. 
Paris,  1825.  P.  257. 

J Ibid.  p.  212. 


BOOK  III. 

STEREOMORPHIC  TEXTURES.  KINETIC 
TEXTURES. 


The  textures  which  next  come  under  observation  are  those  which 
give  solidity  and  figure  to  the  body,  or  the  Stereomorphic  Tex- 
tures ; and  as  in  general  they  are  the  agents  of  movement,  they 
may  be  called  Kinetic  Textures.  These  are  muscle,  sinew,  or 
tendon,  white  fibrous  system,  yellow  fibrous  system,  bone,  cartilage, 
and  fibro-cartilage. 


CHAPTER  I. 

Section  I. 

FLESH,  THEW,  MUSCLE.  Mu?, — Mvig — Musculus, — Lacertus, 

Tori. — MUSCULAR  TISSUE. — Tissii  Miisculaire. 

The  ordinary  appearance  of  the  substance  named  flesh  or  muscle 
must  be  familiar  to  all ; and  it  is  unnecessary  to  enumerate  those 
obvious  characters  which  are  easily  recognized  by  the  most  careless 
observer.  A portion  of  muscle,  when  carefully  examined,  is  found 
to  consist  of  several  animal  substances.  It  is  traversed  by  arteries 
and  veins  of  various  size ; nervous  twigs  are  observed  to  pass  into 
it;  it  is  often  covered  by  dense  whitish  membranous  folds,  (^fascia,) 
or  by  serous  or  mucous  membranes,  all  which  will  be  examined  af- 
terwards ; and  it  is  found  to  contain  a large  proportion  of  fila- 
mentous tissue.  But  it  is  distinguished  by  consisting  of  numerous 
fibres  disposed  parallel  to  each  other,  and  which  may  be  separated 
in  the  same  manner  by  proper  means.  The  appearance,  arrange- 
ment, and  characters  of  these  fibres  demand  particular  notice. 

According  to  Prochaska,  muscle  in  all  parts  of  the  body  may  be 
resolved,  by  careful  dissection,  into  fibres  of  great  delicacy,  as  mi- 
nute as  silk-filaments,  but  pretty  uniform  in  shape,  general  appear- 
ance, and  dimensions.  Their  diameter  appears  not  to  exceed 


396 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


part  of  an  inch,  whatever  be  their  length.  They  seem  all  more  or 
less  flattened  or  angular,  and  appear  to  be  solid  diaphanous  fila- 
ments. Prochaska  appears  not  to  doubt  that  these  muscular  threads, 
{Jila  earned)  are  incapable  of  further  division ; and  he  therefore 
terms  them  primary  muscular  fibres. 

The  microscopical  examination  of  the  atomic  constitution  of  the 
muscular  filament,  which  was  first  attempted  by  Lewenhoeck,  and 
afterwards  prosecuted  by  Della  Torre,  Fontana,  Monro,  and  Pro- 
chaska, was  in  1818  and  1826  revived  by  M.  Bauer,  the  indefati- 
gable assistant  of  Sir  E.  Plome.  From  the  observations  of  this  accu- 
rate inquirer,  each  muscular  filament  appears  to  consist  of  a series 
of  globular  or  oblong  spheroidal  atoms,  disposed  in  a linear  direc- 
tion, and  connected  by  a transparent  elastic  jelly-like  matter.* 

The  primary  muscular  fibres  are  placed  close  and  parallel  to 
each  other,  and  are  united  in  every  species  of  muscle  into  bundles  ; 
(^fasciculi;  Zaccr^z;)  of  different,  but  determinate  size;  and,  accord- 
ing as  these  bundles  are  large  or  small,  the  appearance  of  the 
muscle  is  coarse  or  delicate.  In  the  deltoid  the  bundles  are  the 
largest.  In  the  vasti,,  glutcei,  and  large  pectoral  muscles  the  bundles 
are  greatly  larger  than  in  the  psoce.  In  the  muscles  of  the  face, 
of  the  ball  of  the  eye,  of  the  hyoid  bone,  and  especially  in  those  of 
the  perinaeum,  these  bundles  are  very  minute,  and  almost  incapa- 
ble of  being  distinguished.  The  number  of  ultimate  filaments 
which  compose  a bundle  varies  in  different  muscles,  and  probably 
in  different  animals.  In  a muscular  fibre  of  moderate  size  in  the 
human  subject,  Prochaska  estimates  them  to  vary  from  100  to  200; 
and  in  animals  with  larger  fibres,  at  double,  triple,  or  even  four 
times  that  number,  f There  is  reason  to  conclude,  from  correct 
microscopic  observation,  that  the  largest  do  not  exceed  the  ^th  of  an 
inch,  and  that  the  smallest  are  not  less  than  ^Ith. 

By  cutting  a muscle  across,  these  bundles  are  observed  to  differ 
not  only  in  size  but  in  shape.  Some  are  oblong  and  rhomboidal ; 
others  present  a triangular  or  quadrangular  section ; and  in  some 
even  the  irregular  pentagon  or  polygon  may  be  recognized. 

These  bundles  are  united  by  filamentous  tissue  of  various  degrees 
of  delicacy,  as  may  be  shown  by  the  effects  of  boiling;  and  the 

* The  Croonian  Lecture.  On  the  changes  the  blood  undergoes  in  the  act  of  coagu- 
lation. By  Sir  Everard  Home,  Bart.  V.  P.  R.  S.  Phil.  Trans.  1818,  p.  175. — The 
Croonian  Lecture.  On  the  stnicture  of  a muscular  fibre,  from  which  is  derived  its 
elongation  and  contraction.  By  Sir  E.  Home,  Bart.,  &c.  &c.  Phil.  Trans.  1826,  Part 
2d,  p.  64. 

-f  De  Came  Museulari,  Sect.  i.  Chap.  iii. 


MUSCULAR  TISSUE. 


397 


muscle  thus  formed  is  penetrated  by  arteries,  veins,  and  nervous 
twigs,  and  is  enclosed  by  filamentous  tissue,  which  often  contains 
fat. 

This  fascicular  arrangement  appears  to  be  confined  to  the  muscles 
of  voluntary  motion.  It  is  not  very  distinct  in  the  heart  or  dia- 
phragm ; and  in  the  urinary  bladder  and  intestinal  canal  I have 
not  recognized  it.  Nor  is  the  parallel  arrangement  of  the  ultimate 
filaments  always  strictly  observed  in  the  involuntary  muscles.  The 
component  fibres  of  this  order  of  muscles  are  often  observed  to 
change  direction,  and  unite  at  angles  with  each  other.  This  fact, 
which  was  observed  by  Lewenhoeck,  has  been  verified  by  Prochaska. 

Among  microscopical  observers  it  has  been  recently  the  prac- 
tice to  distinguish  muscular  fibres  into  three  sorts.  Muscular 

fibres  with  cross  stri(B,  or  articulated,  moniliform  fibres,  containing 
the  voluntary  muscles  ; 2d,  INIuscular  fibres  with  the  characters  of 
the  fibres  of  the  middle  arterial  coat,  the  examples  of  which  are 
found  in  the  fibres  of  the  stomach  and  intestinal  tube,  and  the  mus- 
cular coat  of  excretory  ducts,  for  instance,  the  vas  deferens ; and, 
3c?,  Muscular  fibres  with  the  character  of  ligamentous  tissue,  of 
which  the  iris  and  the  tunic  of  the  lymphatic  vessels  are  understood 
to  be  good  examples. 

The  fibres  of  the  voluntary  muscles,  as  seen  in  the  flesh  of  ani- 
mals and  the  human  body,  are  separated  by  maceration  or  boiling 
into  smaller  or  more  slender  fibres,  which  are  the  primitive  fibres. 
The  course  of  these  is  either  straight  or  cmded,  I'arely  spiral.  The 
individual  inflections  of  the  curled  fibres,  (^fihrce  cirrosce,)  are  most- 
ly in  sharp  angles  opposite  each  other,  in  a zig-zag  direction  ; and 
the  angles  of  the  zig-zag  inflections  are  more  or  less  acute. 

The  diameter  of  the  primary  fibres  in  man  and  the  mammalia 
varies.  The  most  are  from  io§oo  to  tosoo  of  a Paris  line,  though 
some  attain  not  the  size  of  of  a Paris  line,  and  others  again 

are  so  thick  that  they  are  from  jo^oo  to  xoioo  ™ breadth.  Only 
the  smallest  approach  the  cylindrical  shape.  The  largest  are  flat,  but 
they  are  never  so  flat  as  inarticulated  muscular  fibres.  The  large 
primary  fasciculi  are  by  dark,  frequent  but  interrupted  longitudinal 
strice  again  divided  into  smaller  fasc2cuh'. 

INIany,  and  especially  the  fine  primary  fibres,  have  a feebly 
granulated  membranous  covering,  void  of  structure,  and  distin- 
guishing them  from  the  fibrous  content. 

The  surface  of  a primary  fasciculus  is  often  covered  with  more 


398 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


or  less  numerous  nucleated  cells,  which  become  distinct  by  immer- 
sion in  vinegar. 

These  are  either  broad,  oblong  oval,  with  nucleated  cells,  or  col- 
lected in  long  or  short,  small  stricB,  acuminated  at  both  ends, 
which  are  incurvated  in  the  semilunar  or  serpentine  form,  like  the 
corpuscles  in  the  roots  of  the  hair;  or  they  may  be  in  rows  of  three, 
four,  or  six  small  dark  nuclei.  The  nuclei  lie  sometimes  detached  ; 
sometimes  alternating,  or  placed  with  their  edges  opposite  each 
other ; sometimes  on  the  surface  of  the  fasciculi  in  great  quantity. 
Most  of  them  are  straight,  with  their  long  axes  parallel  ; but 
sometimes  they  are  oblique  or  transverse. 

The  circumstance  that  principally  distinguishes  the  animal  mus- 
cles from  the  other  two  sorts  of  muscular  fibres,  and  from  all  other 
tissues,  is  the  striated  arrangement  of  fasciculi which  run  both 
transversely  on  the  fasciculi,  and  in  the  longitudinal  direction,  and 
preferably  sometimes  in  one,  sometimes  in  tbe  other  directior. 
Only  in  the  heart,  especially  in  the  neighbourhood  of  the  external 
and  the  internal  covering,  are  seen  fasciculi,  which  are  sometimes 
small-grained,  like  the  smooth  muscular  fibres,  but  are  also  undu- 
lating and  curled,  like  ligamentous  tissue,  and  even  intermediate 
between  the  two.  Others  are  observed  in  the  heart,  and  sometimes 
also  in  the  muscles  of  the  trunk,  which  appear  to  have  a fine-grained 
content ; but  tbe  granules  or  punctula  of  which  are  not  arranged 
in  determinate  lines. 

It  would  exceed  the  limits  within  which  these  notices  ’must  be 
confined,  were  I to  describe  the  whole  as  represented  by  the  micro- 
scope. It  is  enough  to  say  that  the  fibres  of  the  voluntary  muscles 
are  distinguished  by  this  character  of  being  varicose,  like  a string 
of  very  minute  beads,  or  moniliform,  that  is,  consisting  of  granules 
or  nuclei  arranged  in  rows,  so  as  to  form  a beaded  filament ; that 
in  some  of  these  longitudinal  striae  predominate,  in  others  trans- 
verse striae  ; and  in  others,  the  appearance  of  the  longitudinal  striae 
is  such  that  they  seem  to  be  cirrose  or  curled ; and  in  others, 
again,  the  transverse  beading  is  so  strongly  marked,  that  it  seems 
to  obscure  and  disguise  the  longitudinal  arrangement. 

2.  The  second  order  of  muscular  fibres  is  that  of  the  muscles 
formed  after  the  type  of  the  middle  arterial  coat.  If  the  muscular 
layer  of  the  stomach  or  bowels,  or  that  of  an  excretory  duct  is  se- 
parated into  fibres,  there  are  similar,  often  long  flat  lamellce,  as  in 
the  annular  tissue  of  arteries,  or  the  longitudinal  fibrous  coat  of 


MUSCULAR  TISSUE. 


399 


veins,  with  the  same  nuclei^  and  the  same  transformation  of  nuclei 
to  dark  stri<B.  Over  the  middle  of  the  lamellcB^  in  their  long  di- 
rection, passes  sometimes  a longer  or  shorter  and  proportionally 
broader  granular  patch,  sometimes  a long  slender  fine  dark  streak, 
sometimes  an  interrupted  row  of  fine  dark  punctula.  ' 

Besides  these  lamellse,  which  are  most  abundant  in  the  neigh- 
bourhood of  the  serous  coat,  are  individual  fragments  of  broad, 
very  flat,  stiff  fibres.  These  lie  in  the  muscular  coat,  in  general 
parallel  to  each  other,  united  in  greater  or  smaller  numbers  in 
bundles.  They  seldom  pass  by  oblique  anastomoses  into  each 
other.  Between  and  over  them  run  the  nucleated  fibres,  which  often 
form  a similar  net-work,  as  the  nucleated  fibres  of  the  middle  arterial 
coat.  They  are  more  translucent,  more  slender,  and  less  nume- 
rous than  in  the  middle  arterial  coat.  The  breadth  of  the  granulated 
muscular  fibres  is  from  f®  t/o®oo  line;  the  breadth 

of  the  fibrils  about  y o§oo  of  one  line. 

This  species  of  muscular  fibres,  which  are  known  as  flat,  inarti- 
culated  organic  or  involuntary  fibres,  belong  chiefly  to  the  viscera, 
or  organic  and  internal  muscles. 

Of  the  third  species,  embracing  the  iris  and  lymphatic  vessels, 
it  is  unnecessary  to  speak  here. 

The  colour  of  muscle  varies.  In  man  and  the  mammiferous  ani- 
mals, at  least  adult,  it  is  more  or  less  red ; in  many  birds  and  fishes 
it  is  known  to  be  whitish ; in  young  animals  it  is  grayish  or  cream- 
coloured  ; and  the  slender  fibres  which  form  the  middle  coat  of  the 
intestines  in  all  animals  are  almost  colourless.  The  colour  of  the 
muscles  of  voluntary  motion  in  man  is  red  or  fawn ; but  repeated 
washins  or  maceration  in  alcohol  or  alkaline  fluids  renders  them 
much  paler. 

The  examination  of  the  physical  properties  of  muscle  has  occu- 
pied the  industry  of  Muschenbroek,  Croone,  Browne  Langrish, 
Wintringham,  and  others  of  the  iatro-mathematical  school.  I can- 
not perceive  that  minute  knowledge  of  these  properties  is  of  much 
moment  to  the  elucidation  either  of  its  sound  or  its  morbid  states. 
Amidst  the  variable  results  necessarily  obtained  in  such  an  inquiry, 
the  only  point  which  is  certain  is,  that  muscular  fibre  has  much  less 
tenacity  and  mutual  aggregation  thau  most  other  tissues.  It  sus- 
tains much  less  weight  and  force  of  tension  without  giving  way. 

Chemical  analysis  has  not  yet  furnished  any  satisfactory  results 
on  the  nature  of  muscular  tissue ; but  the  general  conclusion  of 
the  numerous  experiments  already  instituted  show  that  muscle  con- 


400 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


tains  fibrin,  albumen,  gelatine,  extractive  matter  (osmazome,)  and 
saline  substances.  It  is  difficult  to  say  how  far  the  gelatine  is  to 
be  regarded  as  proper  to  muscle,  or  derived  from  the  filamentous 
tissue,  in  which  it  certainly  exists.  The  saline  matters  are  common 
to  muscle  with  most  other  organic  substances.  There  is  reason  to 
believe  that  fibrin  in  considerable  quantity,  and  albumen  and  osma- 
zome in  smaller  proportion,  are  the  proper  proximate  principles  of 
muscle.  Though  the  various  proportions  of  these  principles  have 
been  stated  in  numbers  by  chemists,  there  can  be  no  doubt  that  in 
the  present  condition  of  animal  chemistry  it  is  impossible  to  place 
on  them  any  reliance.  It  is  also  to  be  remembered,  that  the 
relative  proportion  of  the  proximate  principles  varies  at  different 
periods  of  life.  In  early  life  the  muscular  fibre  contains  a large 
proportion  of  gelatine,  and  very  little  albumen,  fibrin,  or  osmazome. 
In  adult  age,  however,  the  gelatine  is  very  scanty,  and  the  fibrin 
is  abundant.  The  albumen  and  gelatine  found  in  muscle  seem  to 
be  derived  chiefly  from  the  filamentous  tissue,  and  the  aponeurotic 
intersections. 

During  life  the  muscular  fibre  possesses  the  property  of  shorten- 
ing itself  or  contracting  under  certain  conditions.  These  may  be 
referred  to  tbe  following  heads.  The  will  in  the  voluntary 

muscles.  2d,  Proper  fluids  in  the  involuntary  muscles,  as  the  blood 
to  the  heart,  articles  of  food  or  drink  in  the  stomach,  chyme  in  the 
small  intestines,  excrement  in  the  large  intestines,  urine  in  the  blad- 
der, &c.  M,  Mechanical  irritants  in  all  muscles.  4^/t,  Chemical 
irritants;  and,  5th,  Morbid  products  generated  in  the  course  of 
disease. 

This  property  of  contracting  has  received  various  names ; con- 
tractility (vis  contractilis  of  L.  Bellini),  irritability  (Grlisson),  (vis 
vitalis  of  De  Gorter  and  Gaubius),  excitability,  mobility,  vis  insita, 
vis  propria  of  Haller,  and  the  organic  contractility  of  Bichat. 

It  is  peculiar  to  muscular  fibre,  and  is  found  in  no  other  living 
tissue. 

The  influence  of  the  brain  and  nerves  over  muscular  contrac- 
tion, and  tbe  inquiry  of  the  properties  peculiar  to  muscles,  form  an 
interesting  subject  of  investigation,  on  which  many  facts  have  been 
communicated  since  the  time  of  Haller  and  Whytt,  and  especially 
by  Nysten,  Le  Gallois,  Wilson  Philip,  Brodie,  Bell,  Magendie, 
Mayo,  Flourens,  Fodera,  Rolando,  and  Marshall  Hall.  But  it  is 

too  extensive  to  be  considered  in  this  place ; and,  for  information  on 

4 


MUSCULAK  TISSUE. 


401 


the  subject,  I refer  to  the  ordinary  physiological  works,  and  to 
those  journals  in  which  these  researches  are  detailed.* 

The  muscles  have  been  divided  according  to  the  manner  in  which 
the  phenomena  of  contraction  take  place, — into,  muscles  obe- 

dient to  the  will,  or  voluntary ; 2d,  muscles  not  under  the  influence 
of  the  will,  or  involuntary ; and,  Zd,  muscles  of  a mixed  character, 
the  motions  of  which  are  neither  entirely  dependent  or  independent 
of  the  will. 

The  first  order  comprehends  all  the  muscles  of  the  skeleton ; the 
second  comprehends  the  hollow  muscles,  as  the  heart,  stomach,  and 
intestinal  canal ; and  the  third  comprehends  such  muscular  organs 
as  the  diaphragm,  intercostal  muscles,  bladder,  rectum,  &c. 

Section  II. 

1.  Myositis. — Muscle  is  liable  to  inflammation,  which  may  be 
acute  or  chronic  in  duration,  and  may  differ  according  to  its  kind. 
One  form  of  muscular  inflammation  seems  to  constitute  a species 
of  rheumatism  (Carmichael  Smyth ),f  and  when  this  continues  long, 
it  terminates  in  loss  of  power,  constituting  a local  palsy. 

a.  Myositis  Purulenta. — Another  form,  equally  serious  and  more 
certainly  injurious,  is  the  suppurative  form  of  muscular  inflamma- 
tion. In  this  the  muscular  structure  suppurates  and  sometimes 
sloughs  extensively ; and,  whether  acute  or  chronic,  is  generally  a 
fatal  disease.  The  most  familiar  instance  of  the  chronic  form  of 
suppurative  inflammation  in  muscle  is  that  which  constitutes  lumbar 
abscess, — inflammation  of  the  great  psoas  muscle. j:  Of  this  Schoen- 
mezel  records  a good  example  in  the  person  of  a muscular  young 
man  of  28,  in  whom  the  whole  of  the  psoas  magnus  and  iliacus  of 

* Elementa  Physiologise,  Tome  iv.  Lib.  xi.  Sect.  ii. 

Physiologie  de  PHomme,  par  N.  P.  Adelon,  4 tomes,  8vo.  Paris,  1823-1824. 

Outlines  of  Human  Physiology.  By  Herbert  Mayo,  F.  R.  S.  &c.  3d  Edition.  Lon- 
don, 1833.  4th  Edition.  London,  1836,  8vo. 

Handbuch  der  Physiologie  des  Menschen  fiir  Vorlesungen.  Von  Johannes  Muller, 
Ordentlich  Offentl,  Prof,  der  Anatomie  und  Physiologie  U.  S.  W.  in  Berlin.  Zwey 
Band.  Coblenz,  1835  und  1840, 8\'o. 

Journal  de  Physiologie,  Tomei.  ii.  <Scc.  &c.  Archives  Generales,^(ws-t/». 

t Medical  Communications.  Vol.  II.  p.  21”,  218. 

$ “ The  most  remarkable  and  complete  destruction  of  muscle  which  occurs  from 
suppuration  is  that  which  is  seen  in  the  disease  called  psoas  abscess,  where  the  whole 
or  the  greater  part  of  the  muscle  often  disappears,  and  its  capsule  is  filled  with  the 
matter  of  suppuration.” — Thomson  on  Inflam.,  p.  152. — Lectures,  p.  15.9. 


402 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  right  side  was  destroyed  and  converted  into  purulent  matter, 
forming  a sac  extending  from  the  last  lumbar  vertebra  along  the 
surface  of  the  ilium  to  the  small  trochanter.*  Three  similar  cases 
described  by  Mr  Howsbip  form  the  clearest  account  of  the  anato- 
mical characters  of  this  disease.f  In  such  instances,  since  there 
is  either  no  affection,  or  at  least  no  primary  affection,  of  the  bones 
of  the  spine,  it  must  be  inferred  that  the  disease  consists  in  sup- 
purative inflammation  either  of  the  muscular  tissue,  or  at  least  of  the 
filamentous  tissue  of  the  muscles.  The  structure  of  these  muscles, 
especially  that  of  the  psoas,  is  greatly  more  delicate  than  that  of  any 
other  large  muscle,  and  may  have  some  influence  in  the  destructive 
sero-purulent  secretion  which  follows.  Is  the  muscular  texture  de- 
stroyed or  merely  separated  ? I have  seen  discharged  along  with 
the  fluid  of  lumbar  abscess  capillary  filaments,  brownish,  firm,  and 
evidently  the  remains  of  the  muscular  fibres.  At  the  same  time, 
in  the  dissections  above  quoted,  no  fibres  are  mentioned  in  the 
purulent  cyst.  In  a case  by  Mr  Milroy  fibres  are  stated  to  have 
been  discharged. 

The  acute  form  of  muscular  inflammation  is  more  rare,  but  some- 
times occurs  in  the  muscles  of  the  abdomen,  of  the  chest,  of  the 
thigh  or  leg,  in  persons  of  broken  constitution  and  diseased  habits. 
By  some  authors,  however,  the  muscular  fibre  is  believed  to  be  in- 
capable of  inflammation ; and  the  instances  ascribed  to  it  are  by 
them  said  to  be  inflammation  of  the  intermuscular  cellular  tissue. 
On  this  head,  I refer  to  the  section  on  Diffuse  Inflammation  of  tlie 
Cellular  Membrane. 

/3.  Carditis. — Another  example  of  inflammation  of  muscular 
tissue  is  presented  in  that  of  the  heart.  The  testimony  of  Dr  Baillie 
shows  that  this  is  a rare  disease,  and  is  almost  never  primary,  but 
the  result  of  inflammation  of  the  pericardium,  from  which  it  spreads 
to  the  filamentous  tissue,  and  partly  to  the  muscular  fibres  of  the 
organ.  The  general  accuracy  of  this  statement  is  confirmed  by 
Laennec,  who  contends,  that  though  partial  inflammation  in  minute 
spots  is  not  uncommon,  yet  general  inflammation  of  the  cardiac 
substance,  either  acute  or  chronic,  is  a thing  almost  unknown  in  the 
records  of  medicine.  The  cases  adduced  by  Corvisart  he  regards 
as  examples  of  pericarditis ; and  the  same  may  be  said  of  those  of 

* Francisci  Schoenmezel,  Med.  Prof.  Heidelbergensis  Observatio  de  Musculis  Psoa 
et  Iliaco  suppuratis.  Heidelberg®,  1776.  Frank  Delectus,  Vol.  V.  p.  169. 

•j-  Practical  Observations  on  Surgery  and  Morbid  Anatomy. 


MUSCULAR  TISSUE. 


403 


Dr  Davis.*  The  possibility  of  the  fact,  nevertheless,  he  admits  on 
the  evidence  of  the  case  of  Meckeht  Stronger  proof  he  might 
have  found  in  a case  by  Mr  Stanley,  in  which  the  cut  substance  of 
the  heart  was  exceedingly  dark-coloui'ed  from  injection  of  the  capil- 
laries ; the  fibres  were  soft,  loose,  easily  separable,  and  compres- 
sible between  the  fingers  ; while  sections  of  each  ventricle  exhibited 
numerous  small  distinct  collections  of  dark-coloured  purulent 
matter  among  the  muscular  fasciculi, — some  deep,  approaching  the 
cavity  of  the  ventricle,  others  superficial,  raising  the  pericardium. 
The  muscular  substauce  of  the  auricles  was  softened  and  loaded 
with  blood  ; but  without  purulent  deposits,  j; 

In  this  case,  which  took  place  in  a boy  of  14,  the  chief  symptoms 
were  those  of  intense  inflammatory  fever,  with  great  heat,  deli- 
rium, and  feverishness,  and  some  frontal  headach.  On  one  day 
the  patient  complained  of  pain  in  the  thigh  and  knee ; but  at  no 
time  in  the  whole  course  of  the  symptoms,  which  lasted  only  four 
days,  did  he  give  any  indications  of  pain  within  the  chest.  Death 
was  preceded  by  difficult  breathing.  The  case,  indeed,  was  one  of 
great  acuteness  and  rapidity  in  progress. 

It  cannot  be  denied  that  in  this  case  the  muscular  tissue  of  the 
organ  exhibited  marks  of  inflammation  ; but  the  purulent  deposits 
might  be  seated  in  the  intermuscular  filamentous  tissue,  which, 
though  delicate,  is  abundant. 

In  1828,  Dr  P.  M.  Latham,  after  remarking  the  rarity  of  finding 
purulent  matter  as  a proof  or  effect  of  inflammation  of  the  substance 
of  the  heart,  added  that,  nevertheless,  he  had  met  with  two  examples 
of  this  lesion.  In  one  instance  the  whole  heart  was  deeply  tinged 
with  dark-coloured  blood,  and  its  substance  was  softened ; and  upon 
section  of  both  ventricles,  innumerable  small  drops  of  purulent 
matter  oozed  fi-om  various  parts  among  the  muscular  fibres.  This 
was  the  result  of  a most  rapid  and  acute  inflammation,  which  ter- 
minated in  death,  after  an  illness  of  only  two  days’  duration. 

In  another  instance,  after  death,  which  terminated  an  illness  of 
long  duration,  and  characterized  by  symptoms  referable  to  the  heart, 
a distinct  abscess  was  found  in  the  substance  of  the  left  ventricle, 
closed  externally  by  a portion  of  adherent  pericardium,  and  con- 

• Inquiry  into  the  Symptoms,  &c.  of  Carditis.  By  J.  Ford  Davis,  M D.  Bath 
1808. 

t Memoires  de  I’Academie  de  Berlin. 

t Medico-Chirurgical  Transactions,  Vol.  VII.  p.  323. 


404 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


nected  internally  with  an  ossified  portion  of  the  lining  mem- 
brane.* 

In  the  descriptive  catalogue  of  Mr  Langstaff’s  museum,  are  se- 
veral preparations  in  which  the  muscular  substance  of  the  heart  is 
said  to  have  been  inflamed.  No.  298,  a female  of  46,  303,  a boy 
of  8.  (The  muscular  structure  showed  all  the  signs  of  carditis.) 
303,  a man  of  47.  No  specific  details,  however,  are  furnished. f 
In  the  Morbid  Anatomy  Collection  of  the  University  of  Edinburgh 
is  a preparation  of  a heart,  (P.  1 2,)  in  which  a large  abscess  with 
an  irregular  inner  surface,  which  contained  lymph  and  purulent 
matter,  occupies  the  whole  extent  of  the  septum  cordis,  and  com- 
municates, by  a small  orifice  the  size  of  a quill  with  the  left  ventri- 
cle. In  this  case  inflammation  must  have  affected  the  septum,  per- 
haps the  neighbouring  parts  of  the  left  ventricle,  and  may  have 
eventually  been  concentrated  on  the  septum,  in  which  it  induced 
suppuration,  confined  within  the  walls  of  a distinct  cavity.  Twelve 
months  previous  to  death  the  patient  laboured  under  symptoms  of 
pneumonia,  and  at  last  died  suddenly. 

An  instance  not  less  decisive  is  recorded  by  Mr  Salter  of  Poole, 
in  the  person  of  a man  of  50  years.  The  disease  appears  in  this 
case,  however,  to  have  been  at  first  slow  in  progress,  and  chronic  in 
duration,  as  the  symptoms  continued  for  about  six  weeks.  These 
were  dull,  heavy,  but  not  lancinating  pain,  in  the  lower  part  of 
the  chest,  rather  inclining  to  the  left  side ; much  distressing  oppres- 
sion in  breathing,  aggravated  at  intervals,  and  never  quitting  the 
patient ; frequent  small  pulse  ; considerable  uneasiness  in  the  left 
arm  frequently  recurring,  and  a feeling  as  if  he  could  not  live. 
No  cough  nor  any  sign  of  pulmonary  affection  was  observed.  All 
the  symptoms  assumed  an  aggravated  form  with  great  orthopnoea, 
anxiety,  and  restlessness,  for  sixty-five  hours  only  before  death. 

In  this  case  the  heart  was  rather  larger  than  natural  and  of 
moderate  firmness.  Large  white  and  yellow  clots  were  contained 
within  the  chambers  of  the  organ,  and  marks  of  incipient  ossification 
were  observed  in  the  ascending  aorta,  but  no  disease  in  the  endo- 
cardium or  in  the  valves.  The  muscular  substance  of  the  heart 

“ Pathological  Essays  on  some  Diseases  of  the  Heart  ; being  the  substance  of  Lec- 
tures delivered  before  the  College  of  Physicians.  By  P.  Mere  Latham,  M.  D.,  Physi- 
cian to  St  Bartholomew’s  Hospital.  London  Medical  Gazette,  Vol.  III.,  p.  119. 
London,  1829.  Essay  III. 

t Catalogue  of  the  preparations  illustrative  of  Normal,  Abnormal,  and  Morbid 
Structure,  constituting  the  Anatomical  Museum  of  George  Langstaff,  F.  R.  C.  S.,  &c. 
London,  1842.  8vo. 


MUSCULAE  TISSUE. 


405 


was  of  a light  yellow  colour,  yet  preserving  the  fibrous  texture  of 
muscle  ; and  it  presented  purulent  matter  at  the  surface  of  the  vari- 
ous sections  made  in  it.  In  some  parts  were  observed  small  cavities 
filled  with  purulent  matter,  varying  from  the  size  of  a pin-head  to 
that  of  a small  pea. 

The  pericardium  was  unusually  vascular ; a state  ascribed  by 
the  author  to  inflammation,  but  its  surface  presented  no  lymph.* 
It  is  probable  that  the  inflammatory  state  of  the  cardiac  muscular 
fibres  had  spread  to  the  investing  membrane. 

All  these  cases,  it  must  be  admitted,  afford  examples  of  inflamma- 
tion either  of  the  muscular  substance  of  the  heart,  or  of  the  connect- 
ing filamentous  tissue,  or  of  both.  Indeed,  it  is  not  easy  to  conceive 
the  one  tissue  to  be  inflamed  without  the  other ; and  whether  we 
say  that  the  inflammatory  process  begins  in  the  filamentous  tissue, 
and  thence  spreads  to  the  muscular,  which  is  probable,  or  begins 
in  the  muscular  tissue  and  spreads  to  the  filamentous,  the  result  is 
the  same. 

It  is  impossible  therefore  to  doubt,  that  the  muscular  substance 
of  the  heart  is  liable  to  be  affected  by  inflammation,  and  its  most 
common  product  suppuration ; and  from  the  cases  now  recorded 
it  seems  to  result,  that  the  inflammation  is  often  very  acute  and 
rapid  in  progress,  and  in  other  instances  is  slow  and  more  chronic. 
The  process  also  appears  sometimes  to  attack  the  whole  organ ; in 
other  instances  only  one  part  of  it,  or  after  attacking  the  whole,  to 
become  concentrated  on  one  point. 

Lastly,  Bouillaud  gives  various  examples  of  what  he  denominates 
Inflammation  of  the  substance  of  the  heart.  His  views,  however,  on 
this  subject  are  so  peculiar,  that  I think  they  may  be  more  properly 
introduced  under  a different  head.  Aneurism  of  the  heart  he  con- 
siders as  the  effect  of  inflammation. 

Abscess  and  ulceration  of  muscular  tissue  are  the  result  of  local 
or  punctuate  inflammation.  In  the  former  case,  a cavity,  with 
smooth  walls,  containing  purulent  matter,  is  formed  in  one  region 
of  the  muscular  substance.  In  the  latter  a rugged  irregular  sur- 
face, produced  by  ulcerative  absorption  or  erosion,  takes  place  near 
the  surface  of  the  muscle.  The  examples  of  both  forms,  as  they 
take  place  in  the  heart,  are  the  most  interesting  to  the  pathologist. 
Of  abscess  in  this  organ,  instances  are  given  by  Poterius,  Benive- 
nius,  Cornax,  Nicolaus  Massa,  Pantoni,  and  Laennec.  Of  ulcers 

* Case  of  Carditis  by  Thomas  Salter,  Esq,  Surgeon,  Medico-Chirurgical  Transac- 
tions, Vol.  XXII.  p.  72.  London,  1039. 


406 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


on  the  outer  surface,  instances  were  seen  by  Olaus  Borrichius,* 
RiveriuSjf  Job  a Meekren,|  Peter  de  Marchettis,§  Malpighi,  |1 
Peyer,1T,  Graetz,  and  Morgagni.**  The  ulcer  occurring  in  the 
inner  surface  of  the  heart  was  seen  by  Morgagni,  (Epist.  xxiv.  17,) 
and  by  Laennec,  who  found  one  an  inch  long,  half  an  inch  broad, 
and  more  than  four  lines  deep  in  the  centre,  in  the  inner  surface  of 
the  left  ventricle,  which  was  hypertrophied,  and  at  length  rupured. 

7.  Myositis  emolliens. — To  this  head  may  be  referred  the  softened 
or  pulpy  state  occasionally  observed  in  the  substance  of  the  heart 
in  weak  extenuated  subjects  liable  to  fainting-fits,  and  also  in  those 
cut  off  by  fever.  The  muscular  fibres  then  assume  a light  fawn 
colour  or  pale  yellow,  like  the  dead  leaf,  become  flabby  and  friable, 
and  so  easily  lacerable  as  scarcely  to  sustain  handling.  By  Laen- 
nec this  is  regarded  as  the  result  of  error  of  assimilation  or  defec- 
tive nutrition ; while  Bouillaud  ascribes  it  to  inflammation..  One 
variety  of  softening  appears  to  be  the  consequence  of  inflammation, 
and  may  be  considered  as  gangrene  of  the  heart.  Most  usually, 
however,  it  is  the  result  of  imperfect  nutrition  of  the  organ  during 
disease,  either  chronic  or  subacute. 

2.  Hyper trojjhy. — There  is  reason  to  believe  that  the  condition 
described  as  hypertrophy  of  muscles  is  mere  enlargement  with 
thickening  and  induration  of  the  constituent  fibres,  depending  on 
chronic  inflammation.  It  is  certainly  quite  different  from  the 
enlargement  occasioned  by  exercise,  to  which  it  has  been  erro- 
neously compared.  In  the  heart  and  bladder,  in  which  it  has  been 
most  frequently  found,  not  only  is  tbe  muscular  substance  thick- 
ened and  enlarged,  but  it  is  rendered  hard,  firm,  and  in  some  parts 
almost  cartilaginous.  In  the  early  stage  the  colour  is  simply  brown ; 
subsequently  it  acquires  in  certain  parts  a leaden-gray  tint,  which 
seems  to  depend  on  parts  of  the  muscle  assuming  the  cartilaginous 
induration.  The  substance  of  the  organ  then  cuts  firm,  and  resists 
the  knife.  The  change  seems  either  to  depend  on,  or  to  be  con- 
nected with,  a process  of  chronic  injection  ; for  the  vessels  are  large, 
distended,  and  abundant.  In  the  deltoid  and  biceps  of  the  fencer,, 
and  the  ylutaei  and  yastrocnemii  of  the  dancer,  though  large  and 

* Bartholini,  Acta  Med.  Haf.  Vol.  I.  Obs.  69. 

t Cent.  i.  Ob.  87.  + Obs.  Chimrg.  35. 

§ Observ.  Med.-Chir.  46.  |1  Morgagni,  Ep.  xxv.  17. 

*[J  Method.  Hist.  Anat.  c.  vi.  in  Schol. 

**  Epist.  xvi.  17. 


MUSCULAR  TISSUE. 


407 


well  developed,  no  change  of  this  description  can  be  recognized. 
They  are  indeed  firm  and  tough,  like  the  muscle  of  entire  male 
animals,  but  present  nothing  of  the  morbid  enlargement,  conges- 
tion, and  induration  found  in  the  hypertrophied  heart  and  bladder. 
In  proof  of  the  justice  of  these  views  it  may  be  added,  that  the  in- 
stances in  wdiich  the  muscular  coat  of  the  stomach  is  admitted  to 
be  hypertrophied,  are  those  in  which  scirrhus,  or  some  similar 
chronic  inflammatory  state,  affects  the  collateral  tissues.  (Louis.) 

Hypertrophy  of  muscular  organs  takes  place  most  commonly  in 
connection  with  some  permanent  resistance  opposed  to  their  action. 
Thus  hypertrophy  of  the  heart  is  connected  with  permanent  con- 
traction of  the  aortic  orifice  and  disease  of  the  valves,  or  with  an 
unnaturally  irritant  state  of  the  blood,  as  in  rheumatism  and  disease 
of  the  kidney.  Hypertrophy  of  the  bladder,  in  like  manner,  usu- 
ally takes  place  as  an  effect  of  stricture  of  the  urethra,  and  some- 
times of  chronic  inflammation  or  other  disease  of  the  mucous  coat, 
or  enlargement  of  the  prostate  gland. 

3.  Atrophy  of  muscles,  or  diminution  of  size,  is  more  frequent, 
and  may  arise  either  from  general  disease,  as  in  consumption, 
dropsy,  &c.  or  from  local  debility,  as  in  rheumatism,  palsy,  &c. ; 
or,  in  short,  from  defective  local  nutrition,  or,  as  after  unreduced 
luxations,  from  want  of  exercise  of  particular  muscles.  The  best 
example  of  complete  atrophy  is  that  which  takes  place  in  muscles 
poisoned  by  lead,  which  become  small,  shrunk,  pale,  and  void  of 
irritability. 

4.  Steatosis  ; Adipijication. — I cannot  understand  upon  what 
grounds  the  fatty  degeneration  of  muscle  is  denied  by  Bedard ; 
for  there  is  no  doubt  that  authentic  instances  are  recorded  of  this 
change  occurring  in  the  muscles  both  of  man  and  of  the  lower  ani- 
mals, under  certain  diseases.  Independent  of  its  being  seen  in  the 
muscles  of  the  sheep  by  Vaughan,*  it  has  been  observed  in  those 
of  the  human  subject  by  Haller,  Louis,  Maugre,  Vicq-D’Azyr, 
Dumas,  Emmanuel,  Laennec,  and  Adams.  Louis,  so  early  as 
1739,  in  amputating  the  right  leg,  found  the  gemelli^  plantaris, 
poplitaeus^  solaeus,  the  long  common  flexor  of  the  toes,  the  proper 
flexor  of  the  great  toe,  and  the  tibialis  posticus  converted  into  fat.f 

’ Some  Account  of  an  Uncommon  Appearance,  &c.  By  W.  Vaughan,  M.  D. 
London,  1813. 

t Rapport  sur  line  Observation,  &c.  Journal  General  de  Medecine,  Tome  XXIV. 


408 


GENERAL  AND  RATHOLOGICAL  ANATOMY. 


Maugre  found  the  muscles  of  the  same  region,  excepting  the  ye- 
vielli^  which  were  greatly  diminished  in  size,  converted  into  an  adi- 
pose mass  easily  divisible  by  the  knife.*  Vicq-D’Azyr,  in  an  old 
subject,  saw  the  psoas  and  iliacus^  the  glutcBus  medius  and  minimus, 
the  adductors,  the  deep  posterior  muscles  of  the  leg,  and  the  plan- 
tar muscles,  completely  changed  into  fibro-cellular  fat,  without 
traces  of  remaining  fibre.  In  the  sciatic  portion  of  the  semitendi- 
nosus  and  biceps,  the  gemelli,  the  extensors  of  the  toes,  that  of  the 
great  toe,  and  the  tibialis  anticus  only,  was  it  possible  to  recognize 
fibres  with  distinct  direction.  The  sartorius  presented  the  gradual 
transition  from  muscle  to  fat,  being  muscular  above  and  adipose 
below.  The  fat  into  which  these  muscles  were  changed  is  describ- 
ed as  white,  firm,  contained  in  numerous  minute  cells  ; the  uniting 
cellular  tissue  whitish,  looser,  and  more  separable  than  usual ; and 
the  fat  is  not  deposited  between  its  filaments,  but  forms  part  of 
their  substance.  Examined  by  a good  glass,  it  presents  a mass  of 
soft  transparent  fibres  of  various  diameters,  in  different  parts  of 
their  length.j  Dumas  saw  the  muscles  of  the  fore  part  of  the  chest, 
and  those  of  the  posterior  region  of  the  shoulder  and  arm,  reduced 
to  an  adipose  mass,  contained  in  condensed  cellular  membrane ; 
those  of  the  abdomen  and  the  triceps  adductor  much  changed ; and 
the  glutaeus  maximus  and  first  adductor  half  changed  into  fatty 
matter. I Emmanuel,  in  the  person  of  a woman  of  38,  dead  of  child- 
bed fever,  found  the  abdominal  muscles  entirely  changed  into  fat.§ 

Lastly,  this  transformation  was  seen  by  Laennec  and  Adams  in 
the  human  heart.  The  changed  portions  assumed  a pale-yellow 
colour,  which  is  most  distinct  externally,  and  approaches  to  the  na- 
tural tint  as  it  proceeds  inwards,  at  which  the  muscular  fibres  are 
less  changed.  According  to  an  analysis  by  Cruveilhier,  it  consists 
of  solid  adipocerous  fat,  oily  fluid,  (elaine'),  and  a little  gelatine. 

5.  Elongation  and  shortening  of  muscular  fibres  are  mentioned 
among  morbid  changes. 

6.  Rupture  or  laceration. — Of  this  occurrence  in  muscular  or- 
gans, the  most  important  example  is  that  of  rupture  of  the  muscular 
substance  of  the  heart.  Instances  of  this  have  been  collected  by 

* Rapport  sur  une  Observation,  &c.  Journal  General  cle  Medecine,  Tome  XXIV. 

p.  6. 

t Journal  General  de  Medicine,  Tome  XXVI.  p.  11. 

+ Ibid.  Tome  XXIII.  p.  61. 

§ Ibid.  Vol.  XXIV.  p.  4. 


3 


MUSCULAR  TISSUE. 


409 


Morand,* * * *  Morgagni, f Haller,^  Portal,§  Brera,||  Baillle,  Rostan,1[ 
Blaud,** * * §§  Rochoux,|t  and  Adams.Jt  According  to  the  results  ob- 
tained by  these  observers,  rupture  of  the  heart  is  most  frequent  in 
the  left  ventricle,  which  gives  way  by  a longitudinal  fissure  near 
the  base  and  middle  of  the  ventricle.  In  most  of  the  cases,  this 
rupture  may  be  traced  to  previous  ulceration,  (Morgagni,  Haller, 
Portal,  Brera,  &c.)  and  appears  to  be  the  result  of  the  ulcerative 
process  advancing  from  one  surface  of  the  ventricle  to  the  other. 
Of  rupture  of  the  right  ventricle  too  little  is  known  to  determine 
whether  it  he  also  the  result  of  ulceration  or  not.  So  far,  there- 
fore, as  is  hitherto  known,  laceration  of  the  muscular  substance  of 
the  heart  is  not  so  much  the  consequence  of  being  violently  or  forci- 
bly torn,  as  of  its  being  previously  wasted,  extenuated,  and  weakened. 

Transverse  laceration  of  muscular  fibres,  or  forcible  detachment 
from  the  tendons,  may  happen  in  consequence  of  external  violence. 
This  was  seen  by  ’W’olfius,§§  Wynandts,||||  Cheselden,^1[  Por- 
tal,***' Derame,ttt  Bichat, and  Wardrop.§§§ 

Rupture  of  the  muscular  coat  of  the  stomach,  which  is  not  un- 
frequent, is  in  like  manner  the  consequence  of  ulceration  or  erosion 
of  its  villous  membrane,  and  shall  be  noticed  under  that  head. 

7.  Bony  induration  or  deposition. — This,  though  not  very  fre- 
quent, is  not  unknown.  Morgagni  mentions  in  his  first  case  of 
ulcerative  rupture  a bony  mass  an  inch  thick,  shaped  like  a half 
ring,  being  found  in  the  muscular  substance  of  the  left  ventricle, 
adhering,  however,  to  the  mitral  valves,  also  ossified.  A similar 
case  is  recorded  by  Haller  ; and  to  such  instances  it  may  be  justly 
objected,  that  they  are  not  so  much  examples  of  conversion  of  mus- 
cular fibre  into  bone  as  deposition  of  bony  matter  in  collateral  tis- 
sues progressively  encroaching  on  the  muscular  layer.  One  of  the 
most  distinct  examples  of  seeming  conversion  of  muscular  fibre  into 

* Mem.  (le  I’Acad.  Roy.  des  Sci.  1732. 

t Epist.  xxvii.  2, 5,  8 ; Ixiv.  15.  + Elem.  Physiolog. 

§ Mem.  de  I’Acad.  Roy.  des  Sci.  1784. 

II  Sylloge  Vo).  X.  Opusc.  vi.  p.  202. 

^ Nouv.  Journ.  de  Med.  Avvil,  1820.  Tome  VII.  p.  280. 

**  Bibliotheque  Med.  Aout,  1820. 

•|"t  Sur  les  Ruptures  des  Coeur. 

Dublin  Hospital  Reports,  Vol.  IV. 

§§  Haller  Bibl.  Chir.  I.  p.  223. 

Anatomy,  p.  207. 

Mem.  de  la  Soc.  Med.  I.  p.  159. 

§§§  Medico-Chirurgical  Transact.  Vol.  VII.  ]).  278. 


nil  Verhand.  von  Haarlem 
Anat.  Med.  II.  p.  412. 
ttt  Anat.  Gen.  Tome  III.  p.  234. 


410 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


calcareous  matter  is  given  by  Renaudin  in  the  person  of  a man  of 
33,  subject  to  violent  palpitation.  The  substance  of  the  left  ven- 
tricle was  infiltrated  with  sabulous  and  crystalline  grains.  This 
calcareous  deposition  must  not  be  confounded  with  ossified  pericar- 
dium,— the  usual  example  of  ossified  heart. 

8.  Accidental  productions  and  tumours. — Muscular  structure  is 
liable  to  tubercular  deposition,  to  scirrho-carcinoma,  to  lardaceous 
degeneration,  {lieroma).,  to  encephaloid  tumours,  and  to  the  mela- 
notic deposit,  (Cullen.)  Serous  cysts  {hygrotna)  are  said  to  be  rare; 
but  they  have  occasionally  been  observed. 

9.  Parasitical  animals  have  been  observed  in  the  muscles  of  the 
human  subject.  The  solitary  hydatid  (^cysticercus  cellulosce)  is  not 
uncommon.*  The  latter  especially  has  been  seen  in  the  trapezius, 
serratus  posticus,  psoas,  iliacus,  glutaeus,  and  other  large  muscles, 
(Werner,  Rudolph!,)  and  in  the  heart  by  Morgagni,  (xxi.  4.)  Por- 
tal, Mr  Price,  and  Mr  Evans. 

Mr  D.  Price  found  in  the  muscular  substance  of  the  heart  of  a 
boy  of  ten  years,  who  expired  suddenly,  a large  hydatid,  of  the  cha- 
racter of  which  no  details  are  given.  There  is  good  reason,  never- 
theless, for  believing  that  it  was  an  acephalocyst.f  More  satisfac- 
tory information  is  given  in  the  history  of  another  case  recorded  by 
Mr  Herbert  R.  Evans.  In  this  case,  which  took  place  in  a female 
aged  40,  of  slender  frame  and  weakly  appearance,  the  individual 
became  languid  and  feeble,  and  unable  to  ascend  an  acclivity  or  a 
staircase  without  breathlessness.  Occasionally  she  felt  a sort  of 
sharp  pain  darting,  as  it  were,  through  the  heart.  These  feelings 
lasted  for  five  or  six  months ; when,  in  consequence  of  attempting, 
on  the  20th  April,  to  run  up  stairs  quickly,  she  was  attacked  with 
a paroxysm  of  great  dyspnoea,  accompanied  with  throbbing  and 
pain  in  the  region  of  the  heart.  These  symptoms  continued  with 
little  intermission  for  six  weeks;  and  death  took  place  on  the  1st  of 
June.  The  cavity  of  the  pericardium  contained  about  one  ounce  of 
fluid.  The  membrane  was  covered  by  lymph  over  part  of  the  ante- 
rior surface.  The  apex  of  the  heart  was  lost  or  rendered  round 
and  obtuse  in  a considerable  tumour,  which  communicated  to  the 
touch  a sense  of  fluctuation.  This  tumour,  which  formed  a consi- 

* Bremser,  Traite  Zoologique,  xi.  p.  280. 

t Case  of  Sudden  Death,  in  which  a large  Hydatid  was  found  in  the  Substance  of 
the  Heart.  By  David  Price,  Esq.  Medico-Chirurgical  Transactions,  Vol.  XI. 
p.  274.  London,  1821. 


MUSCULAE  TISSUE. 


411 


derable  projection  encroaching  on  the  cavity  of  the  right  ventricle 
was  globular  and  about  three  inches  in  diameter ; and  when  laid 
open  it  was  found  to  be  a cyst  containing  a number  of  small  cysts 
or  hydatids,  varying  in  size  from  that  of  a pea  to  the  bulk  of  a pi- 
geon’s egg,  the  interstitial  spaces  between  them  being  filled  by  a 
soft  curd-like  substance  of  a yellow  colour.  These  hydatids  were  of 
the  irregular  spheroidal  shape,  and  resembled  in  all  respects  the  ace- 
phalocyst.*  The  muscular  substance  of  the  heart  was  attenuated. 

Trichina  Spiralis. — There  is  also  found  in  certain  circumstances 
in  the  muscles  of  the  human  subject,  a small  capillary  or  hair-like 
worm  coiled  up  in  the  spiral  form.  It  has  from  these  circumstances 
received  the  name  of  trichina  spiralis.  At  the  same  time  it  must  he 
observed,  that  all  cylindrical  worms  are  in  general  coiled  up  in  the 
spiral  or  spherical  form,  so  as  to  constitute  little  balls  contained  within 
membranes.  This  is  probably  the  foetal  or  oviform  stage  of  these 
animals.  In  the  case  of  the  trichina.,  its  presence  is  indicated  at  first 
sight  by  the  appearance  of  little  vesicles  or  bags ; and  when  these 
are  brought  under  the  field  of  the  microscope,  it  is  found  that  they 
contain  hair-like  worms  of  extreme  minuteness  and  delicacy,  coiled 
up  in  the  spiral  shape. 

It  is  not  well  known  under  what  peculiar  circumstances  these 
parasitical  animals  are  found  in  the  animal  body.  In  one  body  in 
which  I saw  them,  the  person  had  died  of  pulmonary  consumption, 
that  is,  tuber culation  and  vomiccE  in  tbe  lungs.  In  others  it  appears 
in  the  bodies  of  persons  in  a bad  state  of  general  health,  emaciated 
and  enfeebled  with  disease  of  the  liver,  or  the  intestinal  tube. 

Tbe  zoological  and  physical  characters  of  the  animal  have  been 
very  accurately  described  by  Mr  Owen,  to  whose  work  I refer  for 
more  ample  details. 

* Case  in  which  a Cyst  containing  Hydatids  was  found  in  the  Substance  of  the; 
Heart.  By  Herbert  R.  Evans,  Esqr  Surgeon.  Medico-Chirurgical  Transactions,  VoL 
XVII.  p.  507.  London,  1832. 


412 


GENERAL  AND  PAinOLOGICAL  ANATOMY. 


CHAPTER  II. 

Section  I. 

SINEW,  TENDON,  Tetldo. 

Sinew  or  tendon  was  united  by  Bichat  with  ligament,  fascia, 
aponeurosis,  and  periosteum,  under  the  general  name  of  fibrous 
system ; and  the  substance  of  this  arrangement  has  been  adopted 
by  Gordon,  Meckel,  and  Beclard.  I am  inclined,  however,  from 
personal  observation,  to  regard  tendon  as  essentially  distinct,  at 
least  in  the  present  state  of  knowledge,  from  these  substances. 
Examined  anatomically,  it  does  not  bear  a very  close  resemblance 
to  any  of  them,  and  in  its  known  chemical  properties,  it  is  consi- 
derably different. 

The  appearance  of  this  substance  must  be  familiar  to  all.  Al- 
most cylindrical  in  shape,  but  flattened  at  the  muscular  end,  and 
tapering  where  inserted,  a tendon  consists  of  numerous  white  lines 
as  minute  as  hairs,  of  satin-like  glistening  appearance,  placed 
parallel  and  close  to  each  other.  A tendon  is  easily  divided,  and 
torn  into  longitudinal  or  parallel  portions,  and  by  the  forceps  very 
minute  fibres  may  be  detached  and  removed  with  ease,  its  whole 
length.  These  facts  show  the  great  tenacity  of  this  tissue,  and  the 
regular  parallelism  with  which  the  component  fibres  are  united. 
The  last  circumstance  distinguishes  them  completely  from  liga- 
ments and  periosteum,  in  which  the  fibres  cross  in  all  directions, 
and  in  consequence  of  which  these  tissues  cannot  be  so  easily  split 
or  separated.  These  fibres  are  united  by  filamentous  tissue. 

Tendon  is  softened  and  more  easily  separable  by  maceration  in 
water  or  alkaline  fluids ; it  is  crisped  by  acid  fluids,  and  rendered 
translucent  by  immersion  in  oil  of  turpentine.  It  has  not  been  in- 
jected, but  it  is  presumed  to  have  blood-vessels  and  absorbents. 
No  nerves  have  been  traced  into  it. 

Tendon  when  boiled  becomes  soft  and  large,  assumes  the  ap- 
pearance of  a transparent  gelatinous  substance;  and  finally,  if  the 
boiling  be  continued,  is  dissolved  and  converted  into  gelatine. 
This  fact,  which  is  well  known  to  cooks,  who  prepare  jellies  from 
tendinous  parts  of  young  animals,  shows  that  tendon  consists  prin- 
cipally of  gelatine,  disposed  in  an  organized  form. 


TENDON. 


413 


A species  of  flattened  tendons,  to  which  the  name  of  aponeurosis 
has  been  given,  may  justly  be  united  with  this  tissue.  The  best 
examples  are  in  the  aponeurotic  or  tendinous  expansion  of  the  ex- 
ternal oblique  muscle  of  the  abdomen,  the  aponeurotic  part  of  the 
occipito-frontal  muscle  of  the  head,  and  the  upper  or  broad  end  of 
the  tendo-Achillis,  The  anatomical  structure  and  the  chemical  pro- 
perties of  each  of  these  varieties  of  animal  substance  are  quite  simi- 
lar, and  somewhat  different  from  that  which  has  been  termed  fascia. 

Section  II. 

In  tendon  inflammation  is  rarely  spontaneous,  and  is  generally 
tbe  result  of  wound,  tear,  bruise,  twist,  wreneb,  or  burn,  when  the 
effects  vary  according  to  the  nature  of  the  injury.  Simple  division 
of  tendon  may  unite  without  much  difficulty,  though  the  medium 
of  union  appears  to  be  filamentous  tissue  with  some  gelatino-albu- 
minous  matter.  In  laceration  complete  reunion  will  depend  upon 
the  extent  of  the  injury.  That  of  the  tendo- Achillis  is  the  most 
frequent.  I have  seen  complete  rupture  of  the  extensor  tendon  of 
the  middle  finger  unite  in  the  course  of  four  months  without  per- 
ceptible trace  of  the  accident,  and  with  complete  restoration  of  the 
functions  of  the  finger  in  about  four  or  five  months  more.  Twists 
or  wrenches  of  the  joints  often  injure  not  only  tendons,  but  liga- 
ments, fasciae,  and  even  cartilage,  and  occasion  inflammation  of  all 
these  textures  at  once.  Of  this  the  injury  termed  sprain  is  an  ex- 
ample. Tendinous  texture  readily  sloughs  under  inflammation, 
either  spontaneous  or  from  injury.  In  whitloe  the  tendons  of  the 
flexor  muscles  of  the  fingers  are  often  killed  and  thrown  off  by  ul- 
ceration ; and  when  tendons  are  injured  by  burns  or  gunshot  wounds 
death  of  their  texture  is  almost  invariable.  In  this  state  tendon 
loses  its  silvery  white  appearance  and  lustre,  assumes  a dull  leaden 
gray  aspect,  and  becomes  thick  and  doughy . 

The  process  of  inflammation  is  most  distinctly  seen  in  wounds  of 
the  extremities,  and  in  lacerations  or  ruptures  of  the  tendons. 
They  become  enlarged,  sometimes  expanded  in  various  affections 
ot  the  joints.  Punctured  or  lacerated  wounds  of  tendinous  struc- 
ture are  sometimes  succeeded  by  tetanic  motions,  which  terminate 
fatally.  Ossification,  so  common  in  the  tendons  of  birds,  is  almost 
unknown  in  the  human  subject ; unless  the  sesamoid  bones  be  ad- 
mitted as  examples  of  this  transformation. 


414 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


CHAPTER  III. 
Section  I. 


WHITE  FIBROUS  SYSTEM.  Ligament^ — m heiMi  •,  Periosteum; 

Dura  Mater  ; Fascia. 

Against  the  formation  of  this  order  of  tissues  fewer  objections 
can  be  urged,  though  ligament  and  periosteum  undoubtedly  furnish 
its  most  perfect  examples;  and  it  may  be  doubted  whether  fascia 
ought  to  he  referred  to  it,  or  arranged  with  tendon  and  aponeu- 
rosis. The  dura  mater,  the  tunica  albuginea,  and  the  fibro-synovial 
sheaths,  are  to  be  regarded  as  compound  membranes. 

Ligament  and  periosteum  are  easily  shown  to  consist  of  strong 
whitish  or  gray  fibres,  as  minute  as  threads  or  hairs,  interwoven  to- 
gether in  various  directions,  and  thus  forming  an  animal  substance 
which  is  not  to  be  split  or  torn  asunder  as  tendon ; but  when  rup- 
tured by  extreme  force  presents  an  irregular  ragged  surface  or 
margin.  Maceration  in  water  or  alkaline  fluids  separates  the  com- 
ponent fibres,  and  shows  their  irregular  disposition  more  distinctly. 
They  are  crisped  by  affusion  of  boiling  water,  or  immersion  in 
acids;  and  they  become  translucent  by  immersion  in  oil  of  turpen- 
tine. 

The  properties  of  this  tissue  are  chiefly  physical.  Those  which 
are  vital  are  referable  to  its  organization  and  nutrition.  It  is 
powerfully  resisting,  and  is  one  of  the  toughest  and  strongest  tis- 
sues in  the  animal  body,  as  is  shown  by  the  numerous  experiments 
recorded  in  the  writings  of  the  iatro-mathematical  physiologists. 
It  is  supposed  to  possess  the  exhaling  ends  of  arteries  and  colour- 
less veins.  No  nerves  have  been  recognized;  and  Bichat  expresses 
his  ignorance  of  absorbents  being  traced  into  it. 

Ligament  when  boiled  yields  a small  portion  of  gelatinej  but 
obstinately  resists  the  action  of  boiling  water,  and  retains  both  its 
shape  and  tenacity  or  cohesion.  The  crispation  which  it  undergoes 
in  boiling  water,  alcohol,  and  diluted  acids,  seems  to  indicate  that 
albuminous  matter  forms  its  chief  chemical  principle. 

As  to  their  mechanical  shape,  the  ligaments  are  divided  by  Bi- 
chat into  two  sorts ; those  in  regular  and  those  in  irregular  bundles. 


WHITE  FIBROUS  SYSTEM. 


415 


The  former  comprehends  all  the  distinct  clusters  of  ligamentous 
structure,  which  sometimes  in  a'cylindrical,  sometimes  in  a flatten- 
ed shape,  connect  the  articulating  ends  of  bones,  and  form  the  la- 
teral ligaments  of  the  various  articulations.  The  latter  consists  of 
those  loose  parcels  of  ligamentous  fibres  which  are  found  in  various 
regions  of  the  skeleton , not  in  regular  cylindrical  or  longitudinal 
bands,  but  irregularly  connecting  bones  not  admitting  of  articular 
motion;  for  instance  at  the  symphysis  pubis  and  the  sacro-iliac 
junction.  The  division  of  Bedard  into  articular,  non-articular  and 
mixed,  is  more  comprehensive  and  more  natural.  The  first  are 
those  which  connect  the  articular  extremities  of  difierent  bones. 
The  second  are  those  which,  attached  to  different  parts  of  the  same 
bone,  convert  notches  into  foramina,  as  in  the  orbitar  arch  and  the 
supra-scapular  hollow,  or  close  openings,  and  give  attaehment  to 
muscles,  as  the  obturator  ligament.  The  last  are  those  which,  like 
the  sacro-ischiatic  or  the  interosseous  ligaments  of  the  fore-arm 
and  leg,  connect  bones  susceptible  of  little  or  no  motion,  and  es- 
pecially give  attachment  to  muscles.  The  two  latter  species  of 
ligaments  approach  closely  in  their  characters,  physical  and  anato- 
mical, to  periosteum,  and  are  probably  to  be  regarded  as  modifica- 
tions of  this  membrane. 

The  articnlar  or  perfect  ligaments  are  naturally  divisible  into  two 
subgenera, — the  capsular  and  the  funicular. 

The  capsular  ligaments  or  the  fibrous  capsules,  (Bichat),  consist 
of  cylindrical  ligamentous  sheaths  attached  all  round  to  the  ends  of 
the  articulating  bones,  and  intimately  interwoven  with  the  perios- 
teal tissue.  Consisting  essentially  of  fibro-albuminous  matter 
strongly  compacted,  they  are  surrounded  by  cellular  tissue,  or  rather 
celluloso-adipose  tissue,  and  are  lined  internally  by  synovial  mem- 
brane. Though  the  most  perfect  examples  of  the  capsular  form  of 
ligament  are  presented  in  the  scapulo-humeral  and  coxo-femoral 
articulations,  less  complete  ones,  nevertheless,  are  seen  in  the  other 
joints.  In  those  of  the  knee  and  elbow,  an  arrangement  of  this 
kind  may  be  demonstrated  ; and  minute  capsules  may  be  shown  to 
connect  the  oblique  articular  surfaces  of  the  vertebrae  with  each 
other. 

The  funicular  ligaments,  which  consist  of  round  chords  or)  flat 
bands,  are  employed  in  eonnecting  the  articular  ends  of  bones  either 
without  or  within  the  cavity  of  the  joint.  Of  those  of  the  former 
description,  the  best  examples  are  seen  in  the  elbow  and  knee-joints. 


416 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


and  in  the  wrist  and  ankle,  where  they  are  termed  lateral  liga- 
ments, (1.  lateralla^  accessoria.)  Of  the  latter  instances,  are  the 
round  ligaments,  {Ugamenta  teretia,^  of  the  shoulder  and  hip-joints, 
and  the  crucial  ligaments  of  the  knee-joint.  These  receive  an  in- 
vestment of  synovial  membrane. 

Of  the  white  fibrous  tissues  one  of  the  most  important  is  that  de- 
nominated jfizscza.  Consisting  in  intimate  structure  of  long  fibrous 
threads  placed  in  parallel  juxtaposition,  sometimes  obliquely  inter- 
woven, and  closely  connected  by  filamentous  tissue,  it  forms  a whit- 
ish membranous  web,  variable  in  breadth,  of  some  thickness  and 
great  strength.  Fascia  is  perhaps,  not  excepting  the  skin,  the  most 
extensively  distributed  texture  of  membranous  form  in  the  animal 
body.  It  not  only  covers,  if  not  the  whole,  at  least  by  far  the 
greatest  part  of  the  muscles  of  the  trunk  and  each  limb,  but  it  sends 
round  each  muscle  productions  by  which  it  is  invested  and  sup- 
ported, and  even  penetrates  by  minute  slips  into  the  substance  of 
individual  muscles.  Of  several  of  the  large  muscles  it  connects 
the  component  parts,  as  is  seen  in  the  recti  abdominis ; to  many  it 
affords  points  of  origin  or  insertion  ; and  to  all  it  furnishes  more  or 
less  investment  and  support.  Most  of  the  tendons,  especially  the 
flexor  and  extensor  tendons,  are  enclosed  by  it ; and  their  synovial 
sheaths  derive  from  it  their  exterior  covering.  At  the  extremities 
of  the  bones  it  is  connected  with  the  ligaments  and  periosteum,  with 
which  it  is  closely  interwoven  ; and  it  forms  a general  investment 
to  the  articular  apparatus. 

Though  fascia  may  thus  be  viewed  as  one  membranous  web  con- 
sisting of  many  parts  all  directly  connected  with  each  other,  it  is 
the  practice  of  anatomists  to  distinguish  its  divisions,  according  to 
the  region  which  they  occupy.  Thus  in  the  fore  part  of  the  neck 
and  chest  is  found  a fascia,  the  relations  and  uses  of  which  have  been 
well  described  by  Mr  Allan  Burns.*  In  the  cervical  region  we 
find  a firm  fascia  descending  from  the  occipital  bone  along  the  ver- 
tebrae, covering  and  connecting  the  muscles  of  each  side  till  it  reaches 
the  loins,  where,  in  the  form  of  a thick  strong  membrane,  it  forms 
the  lumbar  fascia,  (fascia  lumborum. ) It  may  further  be  traced 
over  and  between  the  glutaei  muscles  ; connected  afterwards  with 
the  broad  femoral  fascia,  (fascia  lata ;)  and  thence  over  the  knee 
and  leg  to  the  foot.  Much  in  the  same  manner  a membranous 
web,  thinner  and  more  delicate,  but  of  the  same  structure,  may  be 
* Surgical  Anatomy,  pp.  33,  36. 


WHITE  FIBROUS  SYSTEM. 


417 


traced  from  the  chest  along  the  upper  extremity,  till  at  the  wrist 
it  is  identified  with  the  annular  ligament,  and  in  the  hand  with  the 
palmar  fascia.  In  all  these  situations  the  general  fascial  envelope 
sends  slips  or  productions  {fascias  intermusculares)  between  the 
muscles,  and  into  their  substance.* 

Section  II. 

The  morbid  relations  of  this  system  are  important.  But  in  con- 
sequence of  their  being  often  combined  with  other  tissues,  it  is  diffi- 
cult to  distinguish  them  properly. 

1.  Inflammation  in  various  forms  is  not  uncommon,  and  may 
take  place  either  spontaneously,  or  as  the  effect  of  accident. 

a.  Desmodia. — Inflammation  of  ligament  may  be  spontaneous  or 
the  result  of  injury.  In  the  former  case  it  is  generally  chronic,  and 
is  attended  with  much  thickening  of  the  desmoid  tissue.  The  mor- 
bid action  spreads  to  the  synovial  membrane  on  the  one  side,  caus- 
ing it  to  thicken  and  effuse  morbid  fluid,  and  on  the  other,  to  the 
peridesmoid  cellular  tissue,  which  is  then  infiltrated  with  jelly-like 
fluid,  and  becomes  separated  and  somewhat  indurated  and  granular. 
These  changes  take  place  in  those  forms  of  articular  disease  com- 
monly known  under  the  vague  name  of  loMte  swelling  ; {tumor  al- 
bus  ; fungus  articuli ; der  Grliedschwamm.)  After  some  time  this 
morbid  state  of  the  extra-articular  cellular  tissue  may  proceed  to  sup- 
puration, butw'ithoutnecessarilyopeningthe  cavity  of  the  articulation. 
The  capsular  ligament,  however,  and  even  the  funicular  ones,  may 
be  so  much  changed  in  structure  as  to  become  unfit  for  their  func- 
tions. 

Though  the  process  now  described  is  that  which  takes  place  in 
inflammation  of  ligament  when  primary,  it  is  necessary  to  mention, 
nevertheless,  that  inflammation  in  these  tissues  is  much  more  fi’e- 
quently  the  consequence  of  previous  disease  in  the  synovial  mem- 
brane or  the  articular  cartilages.  This  is  particularly  the  case  in 
the  knee-joint  and  elbow. 

|S.  Ulceration  of  ligament  is  the  result  either  of  traumatic  inflam- 
mation proceeding  to  suppuration,  or  of  suppuration  within  the  ar- 
ticular cavity.  Even  in  the  latter  case  the  desmoid  tissue  itself  is 
rarely  destroyed;  and  the  opening  takes  place  between  its  fibres, 

* Surgical  Anatomy,  by  Abraham  Colies.  Dublin,  1811. 

D d 


418 


GENERAL  AND  PATHOLOGICAL  ANATOAIY. 


which  are  loosened  and  separated.  The  most  frequent  instancesof  ul- 
cerated destruction  of  this  tissue  are  seen  in  destruction  of  the  round 
ligament  and  part  of  the  capsule  in  the  coxo-femoral  articulation, 
and  in  that  of  the  crucial  ligaments  in  the  femoro-tibial  articulation. 

7.  Periostitis.  Periosteum  is  liable  to  inflammation  either  from 
injury,  spontaneously,  or  from  the  operation  of  the  syphilitic  or  the 
mercurial  poison.  In  fractures  of  the  extremities  the  periosteum 
may  be  seen  reddened,  thickened,  and  depositing  semifluid  sub- 
stance, which  appears  to  coagulate  and  unite  the  broken  or  wound- 
ed portions.  When  it  takes  place  spontaneously,  it  is  said  to  de- 
pend on  the  strumous  diathesis,  of  which  it  is  believed  to  bean  in- 
dication. The  membrane  becomes  thick,  painful,  unusually  vascu- 
lar, and,  unless  the  action  subsides,  or  is  controlled  by  art,  semi- 
fluid lymph  is  effused  beneath  it,  and  even  bloody,  sanious,  puru- 
lent matter  may  be  formed.  If  the  inflammation  be  confined  to 
one  spot,  the  thickened  membrane,  with  the  lymphy  induration  be- 
neath it,  gives  rise  to  the  swelling  termed  node  ; {nodus).  When 
suppuration  takes  place,  it  is  too  often  followed  by  caries  of  the 
subjacent  bone  if  of  soft  spongy  texture,  as  in  the  sternum ; or 
death  {necrosis)  if  in  one  of  more  compact  structure,  as  in  the 
skull.  The  distinction,  however,  is  not  invariably  observed ; for 
caries  of  the  tihia  or  ulna  is  seen  to  follow  periosteal  inflammation 
in  these  bones.*  The  appearances  produced  in  the  bones  by  this 
process  belong  to  another  head.  Though  any  part  of  the  perios- 
teum may  be  attacked  by  inflammation,  certain  regions  seem  more 
liable  to  it  than  others.  Node,  whether  from  strumous,  syphilitic, 
or  mercurial  origin,  generally  takes  place  in  parts  of  the  periosteum 
where  that  membrane  approaches  the  surface.  Thus  the  anterior 
surface  of  the  tibia,  the  posterior  internal  surface  of  the  ulna,  the 
outer  surface  of  the  radius,  and  the  anterior  surface  of  the  clavicle 
and  sternum,  are  usual  situations  for  periosteal  inflammation. 
Strumous  periosteal  inflammation  in  the  phalanges  of  the  fingers  I 
have  seen  only  in  young  children.  The  phalanges  are  then  rough 
and  denuded  ; and  the  discharge  of  fetid  sanious  matter  gives  rise 
to  sinuous  ulcers  not  easily  healed.  These  effects  are  to  be  attri- 
buted to  the  suspension  of  the  nutritious  powers  of  the  periosteal 
vessels. 

In  some  instances  inflammation  of  the  periosteum  terminates  in 

* Practical  Observations  in  Surgery  and  Morbid  Anatomy,  &c.  By  John  Howship, 
London,  1816,  p.  176. 


WHITE  FIBROUS  SYSTEM. 


419 


a bony  swelling,  or  a deposition  of  hard  osseous  matter  on  the  sur- 
face of  the  bone.  (^Exostosis.)  The  exact  nature  of  the  process  is 
not  well  understood.  But  there  is  reason  to  believe,  that  what  is 
originally  a deposit  of  lymph  as  in  node,  becomes  eventually  pene- 
trated by  calcareous  matter.* 

The  perichondrium  is  not  very  dissimilar  in  morbid  relations  to 
the  periosteum.  Its  inflammation  may  cause  in  like  manner  thick- 
ening, morbid  deposits,  and  ulceration,  or  even  death  of  the  subja- 
cent cartilage.  Such  is  the  course  of  phenomena  occasionally  ob- 
served in  the  cartilages  of  the  larynx  and  those  of  the  ribs. 

Sparganosis.  Rheumatmnus.  Rheumatism.  Fascial  inflam- 
mation. Though  I have  above  admitted,  on  the  authority  of  Car- 
michael Smyth,  inflammation  of  muscular  tissue  as  a cause  of  rheu- 
matism, I doubt  whether  it  is  entitled  to  the  character  of  a genuine 
or  uniform  pathological  cause  of  that  disease.  Independent  of  the 
fact,  that  the  rheumatic  pains  occur  often  round  joints,  in  which 
there  are  no  muscles,  the  theory  is  at  best  only  an  ingenious  as- 
sumption, and  is  not  supported  by  any  strong  facts  or  arguments. 

Though  rheumatic  pain  is  often  referred  to  muscular  pai’ts,  it  is 
less  frequently  so  than  to  joints  and  parts  covered  by  aponeurotic 
sheaths  axiA.  fascice.  Of  520  cases,  Haygarth  observed  in  388  the 
rheumatic  action  to  be  seated  in  joints,  in  1 18  in  muscular  parts,  and 
in  14  wandering,  general,  or  migrating  through  the  limbs.  Of  170 
cases,  in  154  one  or  more  joints  were  inflamed;  in  33  cases,  both 
joints  and  muscles  were  simultaneously  affected;  and  in  some  cases 
only  were  the  muscles  affected  without  the  joints. 

Though  from  these  facts  Dr  Haygarth  infers  that  acute  rheuma- 
tism is  seated  chiefly  in  the  joints,  he  does  not  attempt  to  ascertain 
the  particular  texture,  in  the  affection  of  which  the  disease  consists. 
It  is  further  manifest,  that  while  it  is  impossible  to  exclude  affection 
of  the  muscles  entirely,  it  results  that  this  affection  is  only  secon- 
dary. The  proof  adduced  by  Dr  Scudamore  from  pressure  of  the 
whole  course  of  a muscle,  and  grasping  its  suhstance  during  severe 
rheumatism,  to  show  that  the  fleshy  part  is  not  the  seat  of  complaint, 
is  entitled  to  attention.  Combined  with  those  already  mentioned, 
and  with  other  considerations  to  be  adduced  immediately,  it  results 
that  the  rheumatic  action  is  seated  in  a texture,  which,  confined 
neither  to  the  site  of  the  joints,  nor  to  that  of  the  muscles  exclu- 
sively, is  common  to  both,  and  which,  from  its  extensive  distribution 
and  complicated  arrangement,  accords  best  with  the  phenomena, 

* Medico-Chirurgical  Transactions,  Vol,  VIII.  p.  90. 


420 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


progress,  and  effects  of  the  disease.  It  is  unnecessary  to  repeat 
the  considerations  above  adduced  from  the  anatomical  relations  and 
characters  of  fascia  and  its  various  divisions.  That  they  are  the 
chief  seat  of  acute  rheumatism  may  be  inferred  from  the  following 
circumstances. 

1.  When  the  rheumatic  action  is  seated  in  muscular  parts,  in- 
stead of  being  confined  to  the  muscular  fibres,  it  may  always  be 
referred  to  the  aponeurotic  membrane  which  covers  or  penetrates 
them.  2.  The  peculiar  pains  of  rheumatism  are  always  most  dis- 
tinct in  those  situations  in  which  several  folds  of  aponeurotic  mem- 
brane meet ; and  their  migrations  may  be  traced  from  one  extre- 
mity to  another  of  an  aponeurotic  membrane,  and  along  the  course 
of  its  principal  divisions.  3.  The  kind  of  pain  which  attends  rheu- 


f| 


matism  resembles  that  of  the  fibrous  tissues  in  general  when  inflamed 


in  undergoing  aggravation  under  the  influence  of  external  heat  and 
during  the  night.  4.  This  view  of  the  seat  of  rheumatic  disorder 
affords  the  most  probable  explanation  of  the  effusion  which  takes 
place  in  the  tendinous  sheaths  (bnrscB  mucosa. ;)  and  even  occasion-, 
ally  within  the  joints ; for  since  each  sheath  is  partly  enveloped  in 
aponeurotic  membrane,  and  every  articulation  is  covered  by  fas- 
cise  inserted  into  the  capsules  or  periosteum,  the  inflammatory  pro- 
cess which  takes  place  in  the  fascia  soon  gives  rise,  as  in  analogous 
cases,  to  effusion,  critical  or  non-critical,  from  the  contiguous  syno- 
vial membrane.  5.  This  view  also  affords  the  most  rational  expla- 
natioia  of  the  fact  remarked  by  all  authors,  that  rheumatism  almost 
never  terminates  in  suppuration.  To  suppose  that  muscle  does  not 
suppm’ate,  is  perhaps  erroneous  from  what  has  been  above  adduced. 
That  fascia  and  fibrous  tissue  in  general  is  little  disposed  to  suppu- 
rate, unless  when  mechanically  injured,  is  manifest  from  a number 
of  circumstances ; and  this  may  perhaps  be  regarded  as  the  true 
explanation  of  the  fact  now  noticed.  6.  It  must  further  be  remarked, 
that  inflammation  in  this  tissue  renders  it  thick,  hard,  and  rigid, 
and  occasionally  causes  between  its  fibres  effusion  of  lymph,  which 
increases  this  thickening,  induration,  and  rigidity.  On  these  changes 
depend  the  immobility  of  rheumatic  parts,  and  the  loss  of  power 
which  follows  long  and  obstinate,  or  neglected  and  repeated,  attacks 
of  the  disease. 

The  question,  whether  there  be  any  thing  peculiar  in  the  nature 
of  rheumatic  inflammation  is  not  undeserving  attention.  This,  how- 
ever, is  not  the  place  for  discussing  it;  and  if  the  views  now  advanced 


i 


li 


WHITE  FIBROUS  SYSTEM. 


421 


be  well-founded,  it  may  be  inferred  that  its  peculiarities  consist  in 
the  anatomical  and  physical  qualities  of  the  texture  in  which  I have 
attempted  to  show  it  is  seated. 

Though  in  acute  rheumatism  the  inflammation  affects  a large 
proportion,  if  not  the  whole  of  the  fascial  system,  local  forms  of 
the  disease  may  occur,  in  which  it  is  confined  with  more  or  less 
accuracy  to  one  or  two  fasciae.  Thus  inflammation  of  the  fascia 
of  the  temporal  and  masseter  muscles  produces  rheumatism  of 
the  temple  and  rheumatic  locked  jaw ; that  of  the  occipito-frontal 
fascia  rheumatism  of  the  head ; that  of  the  cervical  fascia  crick  in 
the  neck ; that  of  the  pectoral  fascia  and  the  intersections  of  the 
intercostal  muscles  spurious  pleurisy  {pleiirodijne ;)  that  of  the  ab- 
dominal fasciae  a rheumatic  belly-ach  ; that  of  the  lumbar  fasciae 
lumbago ; and  that  of  the  aponeurotic  parts  of  the  glutael  muscles 
genuine  sciatica  or  hip- gout. 

2.  Fascia  is  liable  to  undergo,  in  consequence  of  the  operation 
of  certain  agents,  a peculiar  degree  of  thickening  and  rigidity  of 
its  tissue,  with  contraction,  which  has  the  effect  of  impeding  much 
or  abolishing  entirely  the  motions  of  the  parts  with  which  it  is  con- 
nected. Thus  the  fascia  covering  the  joints  is  liable,  in  consequence 
of  articular  rheumatism,  or  that  affecting  the  capsule  and  synovial 
membrane,  to  be  affected  by  more  oiTess  thickening,  rigidity,  and  con- 
traction. The  most  usual  situation,  however,  in  which  this  change  is 
seen  is  the  palmar  aponeurosis,  which  becomes  thickened,  crispated, 
and  shortened,  and  the  effect  of  which  is  to  inflect  forcibly  the  ring- 
finger  into  the  palm  of  the  hand,  preventing  it  from  being  extended, 
then  the  little  finger,  and  afterwards  the  index  and  middle  fingers. 

This  change  is  most  usually  observed  in  those  w'ho  have  to  make 
efforts  with  the  palm  of  the  hand  in  handling  and  compressing  hard 
bodies ; for  instance,  the  hammer,  the  oar,  or  the  whip.  Hence 
wine-dealers,  who  have  to  pierce  wine-casks,  and  coach-drivers,  w'ho 
have  to  handle  the  whip,  masons  and  similar  workmen,  are  liable 
to  suffer  from  this  disorder. 

Patients  feel  the  approach  of  this  malady  by  a sense  of  stiffness 
in  the  palm,  and  difficulty  in  extending  the  finger.  Soon  the  fingers 
remain  incurvated  one-fourth,  one-third,  or  one-half ; in  some  in- 
stances the  tips  of  the  fingers  are  forcibly  incurvated  into  the  palm. 
At  first  is  felt  on  the  palmar  surface  of  the  fingers  and  hand  the 
sensation  of  a cord,  w-hich  is  more  tense  when  any  effort  to  stretch 
the  fingers  is  made,  and  which  almost  entirely  disappears  when  the 


422 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


fingers  are  completely  bent.  Tins  cord  is  rounded  in  form ; and 
its  most  prominent  point  is  at  the  top  of  the  articulation  of  the 
finger  with  the  metacarpal  bone  supporting  it.  There  this  cord 
forms  a sort  of  bridge. 

Little  pain  is  felt  in  the  course  of  this  disease,  which  is  confined 
entirely  to  the  fascia,  and  in  wdiich  the  prominent  feature  is  stiffness 
and  inextensible  incurvation  of  the  fingers.* 

3.  Tyroma. — The  tyromatous  deposition  in  the  tubercular  form 
may  take  place  in  the  periosteum.  The  tubercles,  which  in  colour 
and  physical  qualities  resemble  tyromatous  matter  in  other  situa- 
tions, are  minute,  irregularly  spheroidal,  and  occupy  the  substance 
of  the  membrane.  Their  presence  gives  rise  to  chronic  inflamma- 
tion of  the  membrane,  which  becomes  thick,  spongy,  and  vascular, 
and  is  at  length  detached  from  the  bone  by  effusion  of  purulent 
fluid ; and  their  liquefaction  eventually  forms  a bad  suppuration. 
This  is  one  of  the  forms  of  what  is  usually  termed  strumous  disease 
of  the  bones. 

4.  Chondroma. — Cartilaginous  induration  of  the  white  fibrous 
tissue  is  so  common  that  it  scarcely  requires  separate  notice.  The 
ligaments  are  often  affected  with  this,  especially  in  stiff  and  anky- 
losed  joints,  and  appear  then  to  acquire  the  properties  of  genuine 
cartilage.  This,  which  may  be  regarded  as  one  of  the  effects  of 
chronic  inflammation,  with  long  disease  of  the  articular  tissues,  I 
conceive,  is  what  is  meant  by  inordinate  rigidity  of  the  ligaments, 
much  dwelt  on  by  practical  authors.  It  never  occurs,  I am  satis- 
fied, unless  under  the  circumstances  now  mentioned.  In  the  peri- 
osteum I have  seen  the  same  change  resulting  from  the  same 
causes.  It  takes  place  after  compound  fractures,  occasionally  after 
amputation,  and,  in  short,  in  all  circumstances  in  which  the  raern-,, 
brane  is  inflamed. 

5.  Ossification. — Partial  or  general  conversion  into  bone,  though 
not  uncommon  in  the  v.'hite  fibrous  system,  is  nevertheless  restrict- 
ed in  a peculiar  manner.  It  is,  for  instance,  much  less  frequent 
in  ligament  than  in  periosteum ; and  in  fascia  it  is  scarcely  known. 
Ossification  in  ligament  commences  at  the  point  connected  with  the. 
periosteum ; and  it  is  uncommon  to  observe  it  extend  over  the 


• Lefons  Orales  de  Clinique  Chirurgicale  Faites  a I’Hotel  Dieu  de  Paris.  Par  M, 
le  Baron  Dupuytren,  Chirurgien  en  Chef.  Recueillies  et  Publiees  par  MM.  le  Doc-  ' 
teurs  Brierre  de  Boisraont  et  Marx,  2xieme  edit.  Tome  IV.  Paris,  1839.  Article  xL 
p.  473.. 


WHITE  FIBROUS  SYSTEM. 


423 


whole  ligament,  unless  in  cases  of  anchylosis  and  stiff  joint,  in  which 
it  is  rather  a sort  of  cartilaginous  rigidity  and  induration  than 
actual  conversion  into  bone.  The  former  appears  to  be  the  origin 
of  the  bony  nodules  or  sesamoid  bones  occasionally  found  in  the 
substance  of  the  funicular  ligaments.  In  the  irregular  filaments, 
especially  the  sacro-ischiatic,  it  is  not  unusual  to  find  ossification  in 
aged  subjects. 

That  the  periosteum  may  be  converted  into  bone  is  a point  which 
has  been  alternately  admitted  and  denied  during  a whole  century. 
While  the  numerous  experiments  of  Du  Hamel* * * §  and  Trojaf  tend 
to  establish  it  in  the  affirmative,  it  is  rendered  very  doubtful  by  the 
facts  and  arguments  of  Leveille  and  Richerand.  From  the  expe- 
riments of  the  former  authors  it  results  that  the  periosteum  becomes 
thick,  highly  vascular,  very  firm,  and  eventually  acquires  a bony 
hardness  in  its  inner  layer  under  either  of  the  following  circum- 
stances ; — Is^,  when  it  is  detached  from  the  bone ; 2t?,  after  frac- 
tures during  the  process  of  reunion ; and  when  the  marrow 

or  its  membrane  is  destroyed.  That  in  the  two  former  instances 
the  inner  layers  of  the  periosteum  truly  undergo  conversion  into 
bone,  may  be  regarded  as  established,  not  only  by  the  experiments 
of  Du  Hamel  and  Troja,  but  by  those  of  Dupuytren,|  Cruveil- 
hier,§  Breschet,||  and  Villerme,^  and  especially  by  the  phenomena 
of  reunion  after  fractures  by  gunshot  wounds.  The  third  case, 
that  of  injury  of  the  marrow  and  its  vessels,  is  perhaps  more  ambi- 
guous. It  appears,  nevertheless,  from  the  experiments  of  M.  Cru- 
veilhier,  that  only  when  the  medullary  membrane  is  destroyed, 
with  the  permanent  continuance  of  a foreign  body  in  the  canal, 
ossification  at  the  surface  of  the  bone  takes  place  at  the  expense 
not  only  of  the  periosteum,  but  even  of  the  muscles.  The  condi- 
tion necessary  for  the  ossification  of  the  periosteum  after  injury  ap- 
pears to  be,  that  the  concomitant  inflammation  produces  albuminous 
effusion  only ; for  when  the  membrane  is  in  contact  with  purulent 
matter,  effusion  of  albuminous  or  coagulable  fluid  is  precluded ; 
and  in  this  sense  only,  perhaps,  are  the  inferences  of  Leveille  to  be 
admitted. 

* Mem.  cle  ]’Acad.  des  Sciences,  1741,  &c. 

-f-  Mem.  de  la  Societe  Roy.  de  Med.  1776. 

J Journal  Univers.  des  Sci.  Med.  T.  xx.  p.  131. 

§ Essai  sur  I’Anatomie  Pathologique,  Tome  ii.  p.  25,  &c.  Paris,  1816. 

II  Quelques  Rechercli.  Hist,  et  Exper.  sur  le  Cal.  Paris,  1819. 

f Quart.  Joum  of  Foreign  Medicine,  No.  ii.  London,  1819. 


424 


GENERAL  AND  RATHOLUGICAL  ANATOMY. 


On  this  subject,  however,  I shall  have  occasion  to  make  some 
observations  in  the  fourth  chapter,  when  treating  of  Nekrosis. 

In  fascia,  I have  said,  and  I may  add  tendinous  aponeurosis, 
ossification  is  almost  unknown.  To  this  head,  however,  may  per- 
haps be  referred  the  instance  recorded  by  Hoernigk  of  alleged  os- 
sification of  the  tendinous  centre  of  the  diaphragm  and  part  of  the 
intercostal  muscles;*  that  of  chondro-osteoid  induration  of  the  right 
half  of  the  diaphragm  by  Lieutaud  from  the  Petersburgh  Trans- 
actions ;f  a similar  case  seen  by  Leveille  in  1793;  and  that  of  ossi- 
fication of  the  tendinous  centre  of  the  same  muscle  mentioned  in 
the  body  of  Collalto  by  Cruveilhier.  The  instance  of  cartilaginous 
induration  of  the  deep-seated  muscles  of  the  leg,  found  by  Dupuy- 
tren  in  the  body  of  a man  affected  with  Arabian  elephantiasis, 
though  considered  by  Cruveilhier  as  ossification  of  the  muscles,  is 
probably  with  greater  justice  to  be  viewed  as  of  the  same  descrip- 
tion.! 

A singular  instance  of  ossification  of  the  fibrous  septum  of  the 
corpus  cavernosum,  so  complete  as  to  requre  excision,  occurred  to 
Dr  M‘Lellan  of  Baltimore  in  the  United  States.§ 

6.  Some  of  the  forms  of  osteosteatoma  and  osteosarcoma  appear 
to  originate  in  the  periosteum.  The  former  is  generally  an  en- 
cysted tumour,  and,  according  to  the  observation  of  Meckel,  may 
primarily  affect  this  membrane.  The  latter,  from  its  anatomical 
characters,  bears  a greater  affinity  with  this  source ; and  I think, 
in  several  cases,  I have  been  able  to  trace  osteo-sarcomatous  tu- 
mours to  the  periosteum.  II  Of  neither,  however,  are  the  local  re- 
lations, when  examined,  so  simple  or  distinct  as  to  enable  the  pa- 
thologist to  determine  the  question  positively.  Does  true  cancer 
{scirrho-carcinoma)  ever  originate  in  the  periosteum?  The  tu- 
mours to  which  this  name  has  been  applied  are  rather  examples  of 
osteosarcoma  than  of  genuine  scirrhus.  Such  at  least  is  the  cha- 
racter of  most  of  the  tumours  of  the  maxillary  sinus. 

7.  When  the  encephaloid  degeneration  (^fungus  hcematodes')  ap- 
pears in  the  periosteum,  it  may  often  be  traced  to  the  contiguous 
muscles,  or  to  some  of  the  adjoining  articular  tissues,  or  to  the  bone 
itself.  In  the  latter  case,  however,  it  is  almost  impossible  to  de- 

* Haller,  Disputationes  Medico-Pract.  Tom.  VI.  p.  344. 

+ Historia  Anatomico-Med.  Tome  II.  p.  99. 

^ Essai  sur  TAnatomie  Pathologique,  Tome  II.  p.  73. 

§ Philadelphia  Monthly  Journal,  Nov.  1827.  Vol.  I.  No.  6,  p.  256. 

11  Mr  Howship  in  Medico-Chir.  Trans.  Vol.  VIII.  p.  95  and  99  ; where  the  same 
conclusion  is  formed. 


3 


AVHITE  FIBROUS  SYSTEM. 


425 


termine  whether  the  hone  or  periosteum  were  the  original  seat  of 
the  disease. 

8.  Punctured  and  contused  wounds  of  the  white  fibrous  system, 
especially  of  the  ligaments  and  periosteum,  are  liable  to  be  succeed- 
ed by  tetanic  motions,  more  or  less  general ; and  wounds  with 
much  laceration  in  subjects  of  all  ages  are  too  often  followed  by 
gangrenous  inflammation  terminating  fatally.  This  I have  seen 
several  times,  not  only  in  compound  dislocations  of  the  larger 
joints,  but  in  contused  wounds  of  the  feet,  in  which  the  white  fi- 
brous system  is  much  injured.  Partial  laceration  of  the  capsular 
ligaments  occasionally  takes  place  in  dislocation.  (A.  Bonn,  De- 
sault, Howship,  Sir  A.  Cooper.) 

9.  Dcsmectasis.  Excessive  relaxation  is  mentioned  as  an  abnor- 
mal state  occurring  in  ligaments.  It  is  the  result  of  repeated  over- 
distension, as  in  luxation  or  subluxation,  or  in  consequence  of  the 
weakness  sometimes  left  after  local  inflammation,  or  long-continued 
disease.  Though  this  may  happen  to  the  ligaments  of  any  joint, 
it  is  most  frequently  seen  in  those  of  temporo-maxillary  and  sca- 
pulo-humeral  articulations.  Distortions  of  the  spine  are  ascribed 
by  Dr  Harrison  to  relaxation  of  the  vertebral  ligaments.  But  if 
this  be  the  cause,  it  is  merely  as  the  efiect  of  previous  disease ; and 
it  is  quite  inadequate  to  produce  the  extreme  deformity  so  frequent- 
ly observed  in  the  vertebral  column  of  young  persons. 

On  the  new  or  accidental  production  of  the  fibrous  system  in 
other  tissues,  much  has  of  late  years  been  written  by  Bichat,  Bayle, 
Laennec,  and  other  foreign  authors.  Without  positively  denying 
the  principle,  that  the  fibrous  system  may  be  accidentally  developed, 
I think  with  Meckel,  that  in  general  these  products  partake  of  the 
cartilaginous  character.  The  notice  of  them,  therefore,  will  more 
conveniently  be  introduced  under  that  head. 


426  GENERAL  AND  EATHOLOGICAL  ANATOMY. 

CHAPTER  III. 

YELLOW  FIBROUS  SYSTEM.  Ligamenta  Flava  ; Ligamentum  Nucha. 
Tissu  Fibreux  jaune,  Bedard. 


The  yellow  ligaments  {ligamenta flavai)  which  connect  the  spinous 
processes  of  the  vertebrae  to  each  other  differ  considerably  from  the 
articular  ligaments  and  the  periosteum,  and  suggested  to  Bedard 
the  necessity  of  establishing  a particular  order  of  fibrous  tissues,  to 
whicb  he  applied  the  denomination  yellow  or  tawny  fibrous  sys- 
tem. Under  this  he  includes  also  the  proper  membrane  of  the  ar- 
teries ; that  of  the  veins  and  of  the  lymphatic  vessels ; the  membranes 
which  form  excretory  ducts ; that  of  the  air-passages ; the  fibrous 
covering  of  the  cavernous  body  of  the  urethra,  and  perhaps  that 
of  the  spleen.  The  actions  and  occasional  distensions  of  which 
these  parts  are  the  seat  require,  it  is  said,  a tissue,  the  resistance 
and  elasticity  of  which  may  at  once  counteract  any  extraordinary 
effort,  and  cause  them  to  resume  their  original  state,  when  the  dis- 
tending cause  ceases  to  operate.  In  the  lower  animals  this  pur- 
pose is  more  conspicuous  than  in  the  human  subject.  The  posterior 
cervical  ligament  (ligarnentum  nucli(B.i  Arab. ; cervicis,  Lat.)  coun- 
teracts the  tendency  to  inclination  of  the  head ; and  a similar  mem- 
brane strengthens  the  abdominal  parietes,  and  resists  the  weight 
and  distending  power  of  the  viscera.  In  the  feline  tribe,  an  elastic 
ligament  inserted  into  the  unguinal  phalanges  retains  them  ex- 
tended so  long  as  the  muscles  do  not  alter  their  direction.  The  | 
shells  of  the  bivalve  molluscous  animals,  as  oysters,  mussels,  &c.  ,^ 
are  opened  by  a similar  fibrous  tissue  as  soon  as  the  muscles  which"  M 
close  them  are  relaxed.  J 

The  disposition  of  the  component  fibres  is  the  same  in  the  elastic  ■ 
as  in  the  common  white  fibrous  system.  Their  colour,  which  is  3 
yellow  or  tawny,  is  generally  more  distinct  in  the  dead  subject.  ^ 
They  are  said  to  be  less  tenacious,  but  more  elastic  than  those  of/§ 
any  other  tissue.  In  respect  to  chemical  composition,  they  appear;.! 
to  contain  a considerable  quantity  of  fibrine  in  a peculiar  condition, 
combined  with  some  albumen  and  a little  gelatine.  Their  other 
properties  are  not  very  conspicuous.  I 

The  morbid  changes  incident  to  them  are  quite  unknown.  9 


BONE. 


427 


CHAPTER  IV. 

Section  I. 

Bone,  oaov.  Os, — Ossa, — Tissu  Osseux,  die  knochen. 

No  animal  substance  has  been  more  frequently  or  thoroughly 
examined  than  bone ; and  the  greatest  difficulty  in  describing  its 
general  anatomy  consists  in  selecting  and  concentrating  informa- 
tion.* 

Several  attempts  have  at  different  times  been  made  to  ascertain 
the  atomic  constitution  of  bone,  but  without  much  success.  Mal- 
pighi, though  he  corrected  the  extravagant  fiction  of  Gagliardi  re- 
garding the  osseous  plates  and  nails,  fancied  bones  to  be  composed 
of  filaments,  which  Lewenhoeck  represented  as  minute  hollow  tubes; 
(tubuli.)  By  Clopton  Havers,  again,  the  ultimate  particles  of  bone 
were  imagined  to  be  fibres  aggregated  into  plates  {lamin<B)  placed 
on  each  other,  and  traversed  by  longitudinal  and  transverse  hollows 
or  pores,  This  view  was  adopted  by  Courtial,|  Winslow,§ 

Palfyn,||  IMonro,^  and  Reichel,**  the  last  of  whom  was  at  some 
pains  to  demonstrate  this  arrangement  of  plates  and  minute  tubes  by 
microscopical  observation. 

The  justice  of  these  notions  was  first  questioned  by  Scarpa,  who, 
in  1799,  undertook  to  show,  by  examinations  of  bone  deprived  of 

■*  The  principal  authors  on  the  structure  of  bone  are  Dominici  Gaghardi,  AvMorae 
Osshim,  novis  inventis  illmtrata.  Romae,  1 689. 

Malpighi,  De  Ossium  atnictum  ex  Op.  Post,  who  corrected  the  fictitious  riews  of  the 
former.  Marcelh  Malpighii  Opera  Omnia  Tomis  Duobus  Comprehensa.  Londini, 
1686.  Foho.  Opera  Posthuma.  Londini,  1697. 

Clopton  Havers,  Osteolor/ia  Nova,  or  Some  New  Observations  of  the  Bones  and  the 
Parts  belonging  to  them.  London,  1691. 

De  La  Sone,  Memoire  sur  I'organisation  dcs  os,  Mem.  de  PAcademie,  1754. 

G.  C.  Reichel,  de  Ossium  ortu  atque  structura.  Lips.  1760. 

Ext.  in  Sandifort  Thesaur.  VoL  ii.  p.  171. 

Antonii  Scarpa,  de  Peiiitiori  Ossium  Structura  Comment.  Lips.  1799.  Republished 
in  Be  Anatome  et  Pathologia  Osskini,  Commentaiii,  Auctore  A.  Scarpa.  Ticini,  1827. 

Papers  by  Mr  Howship  in  the  sixth  and  seventh  volumes  of  the  Medico-Chirurgicai 
Transactions. 

•f-  Osteologia  Nova.  London,  1691,  p.  34,  37,  41,  46. 

J Nouvelles  Observations  sur  les  Os.  A.  Leide,  1709. 

§ Exposition  Anatomique.  ||  Anatomie  Chirurgicale. 

Anatomy  of  the  Bones.  **  De  Ossium  Ortu,  &c.  § v. 


428 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


its  earth  by  acid,  and  long  macerated  in  pure  water,  that  it  consists, 
both  externally  and  internally,  of  reticular  or  cellular  structure.* 
So  far  as  I understand  what  idea  this  eminent  anatomist  attaches 
to  the  terms  reticular  and  cellular,  I doubt  whether  this  opinion  is 
better  founded  than  any  of  the  previous  ones.  After  repeating  his 
experiment  of  immersing  in  oil  of  turpentine,  bone  macerated  in 
acid,  1 cannot  perceive  the  reticular  or  cellular  arrangement  which 
Scarpa  describes  as  demonstrable  in  bone.  It  must,  I conceive,  be 
the  result  of  the  mode  of  preparation.  Recently  bone  has  been 
submitted  to  microscopic  examination  by  Mr  Howship,  who  has 
been  led  to  revive  the  opinion  of  the  existence  of  minute  longitu- 
dinal canals,  as  maintained  by  Lewenhoeck,  Havers,  and  Reichel, 
but  with  Scarpa  maintains  the  ultimate  texture  not  to  be  laminated 
but  reticulated. I Lastly,  the  existence  of  fibres  and  plates,  which 
is  admitted  by  Blumenbach,  Soemmering,  Bichat,  and  Meckel,  ap- 
parently on  insufficient  grounds,  is  to  be  viewed  as  an  appearance 
produced  by  the  physical,  and  perhaps  the  chemical  qualities  of  the 
proper  animal  organic  matter  of  which  bone  consists.  Though  it  does 
not  demonstrate,  it  depends  on,  the  intimate  structure  of  this  body. 

The  minute  structure  or  atomic  constitution  of  bone  is  probably 
the  same  in  all  the  pieces  of  the  skeleton,  and  is  varied  only  in 
mechanical  arrangement.  When  a cylindrical  bone  is  broken,  and 
its  surfaces  are  examined  with  a good  magnifying  glass ; or  when 
minute  splinters  are  inspected  in  a powerful  microscope,  it  appears 
to  be  a uniform  substance  without  fibres,  plates,  or  cells,  penetrated 
everywhere  by  minute  blood-vessels.  Its  fracture  is  uneven,  pass- 
ing to  splintery.  In  the  recent  state  its  colour  is  bluish-white  ; but 
in  advanced  age  the  blue  tinge  disappears.  Delicate  injection,  or 
feeding  an  animal  with  madder,  shows  the  vascularity  of  this  sub- 
stance. 

To  have  a clearer  and  more  accurate  idea  of  the  minute  struc- 
ture of  bone,  it  is  requisite  to  break  transversely  a long  bone,  and 
examine  its  fractured  surface  by  a good  glass,  or  to  examine  in 
the  same  manner  the  transverse  fracture  of  a long  bone  which  has 
been  burnt  white  in  a charcoal  fire.  The  broken  surface  presents 
a multitude  of  minute  holes,  generally  round  or  oval,  which  are 
larger  towards  the  medullary  cavity,  but  become  exceedingly  mi- 
nute towards  the  outer  surface  of  the  bone.  Of  these  minute  holes 

* De  Penitiori  Ossium  Structura,  4to.  Lips.  1799. 

+ Experiments  and  Observations,  &c.  Medico-Chir.  Trans.  Vol.  vi.  p.  287,  and  Micro- 
scopic Observations,  &c,  Vol.  vii.  p.  392,  &c. 


BONE. 


. 429 


no  part  of  the  bone,  however  compact  in  appearance,  is  destitute ; 
and  the  only  difference  is,  that  they  are  more  minute,  and  more 
regularly  circular  towards  the  outer  than  towards  the  medullary 
surface.  These  circular  holes  are  transverse  sections  of  the  tubuli 
of  Lewenhoeck,  the  longitudinal  pores  of  Havers,  {Osteologia,  p.  43 
and  46,)  the  pores  and  tubuli  of  Reichel,  and  the  longitudinal  ca- 
nals of  Howship.  They  communicate  with  each  other  by  means 
of  their  great  multiplicity  and  slight  obliquity  and  tortuosity. 
They  contain  not  blood-vessels  exclusively,  but  divisions  of  the 
vascular  filamentous  tissue,  which  secretes  the  marrow.  They  are 
seen  very  distinctly  in  bones  which  have  been  burnt.  After  many 
careful  examinations,  I have  never  been  able  to  observe  holes  in 
longitudinal  fractures  of  bones ; and  I therefore  infer  that  there 
are  no  transverse  pores. 

These  capillary  pores  are  seen  in  the  flat  bones  of  the  skull.  I 
find  them  in  the  compact  matter  of  the  outer  and  inner  tables  of 
the  occipital  bone  when  well  burnt,  in  which  they  seem  to  pass 
gradually  from  the  lattice-work  of  the  diploe  to  the  distinct  pores 
of  the  tables.  I doubt,  however,  whether  these  pores  can  be  said, 
as  in  the  long  bones,  to  indicate  canals.  They  seem  rather  to  be- 
long to  a very  delicate  cancellated  structure. 

These  pores  are  most  numerous  and  distinct  in  the  bones  of 
young  subjects.  In  the  humerus  of  a child  burnt  to  whiteness,  I 
find  them  to  be  large,  numerous,  and  distinct,  even  at  the  perios- 
teal sm’face  of  the  bone.  In  that  of  a young  man  of  28,  they  are 
larger,  more  numerous,  and  more  distinct  than  in  bones  of  older 
subjects.  In  a very  dense  ulna  before  me,  though  distinct  through 
a good  glass,  they  are  exceedingly  minute,  and  quite  imperceptible 
to  the  naked  eye. 

Though  these  circular  pores  are  most  distinct  in  calcined  bones, 
and  might  therefore  be  thought  to  be  the  result  of  the  burning, 
yet  that  they  are  not,  I infer  from  the  circumstance  that  they  are 
seen  by  a good  glass  in  the  transverse  fracture  of  splinters  of  the 
femur  and  other  large  bones. 

If  a portion  of  bone  be  immersed  in  sulphuric,  nitric,  muriatic, 
or  acetic  acid  properly  diluted,  it  becomes  soft  and  pliable,  and 
when  dried,  is  found  to  be  lighter  than  before ; yet  it  is  impossible 
to  discover  that  any  particle  of  its  substance  has  been  mechanically 
removed,  or  that  its  shape  and  appearance  are  changed. 

If  a portion  of  bone  be  placed  in  a charcoal  fire,  and  the  heat  be 


430 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


gradually  raised  to  whiteness,  it  burns  first  with  flame,  and  at 
length  becomes  quite  red.  If  then  it  be  removed  carefully  and 
slowly  cooled,  it  appears  as  white  as  chalk,  is  found  to  be  very 
brittle,  and  to  have  lost  something  of  its  weight.  Yet  neither  in 
this  case  does  any  part  of  its  substance  appear  to  be  removed,  nor 
is  its  mechanical  figure  or  appearance  altered. 

Chemical  examination,  however,  informs  us  that  in  the  first  case 
a portion  of  earthy  matter  (phosphate  of  lime)  is  removed  by  the 
agency  of  the  acid,  and  held  suspended  in  the  fluid,  while  the  pliant, 
but  otherwise  identical  piece  of  bone  consists  chiefly,  if  not  entirely, 
of  animal  matter ; and  that,  in  the  second  case,  this  animal  matter 
is  removed  by  destructive  decomposition,  while  the  earthy  matter 
is  left  little  changed  by  the  action  of  fire.  It  is  therefore  to  be 
concluded,  that  every  particle  of  bone,  however  minute,  consists  of 
animal  or  organic,  and  earthy  or  inorganic  matter  intimately  united; 
and  that  it  is  impossible  to  touch  with  the  point  of  the  smallest 
needle  any  part  of  bone  which  is  not  thus  constituted.  A piece  of 
bone  consists  not  of  cartilaginous  fibres  varnished  over,  as  Heris- 
sant  imagined,  with  earthy  matter,  but  of  a substance  in  which 
every  constituent  atom  consists  essentially  of  animal  and  earthy 
matter  intimately  combined. 

There  is  therefore  no  rational  ground  for  dividing  osseous  tissue 
into  compact  and  spongy,  as  the  older  anatomists  did  ; for  though 
the  middle  or  solid  parts  of  long  bones  are  denser  and  heavier  than 
the  ends  of  these  bones,  or  the  bodies  of  the  vertebrae,  the  differ- 
ence consists  not  in  chemical  composition,  but  in  mechanical  ar- 
rangement and  structure.  On  dividing  the  head  of  a long  bone, 
the  lattice-work  or  comce///,  as  they  are  named,  are  formed  by  many 
minute  threads  of  bone,  crossing  and  interlacing  with  each  other. 
But  each  thread  is  quite  as  dense,  and  consists  of  the  same  quan- 
tity of  animal  and  earthy  matter  as  the  most  solid  part  of  the  centre  ‘ 
of  the  same  bone.  These  threads,  however,  instead  of  being  dis-' 
posed  closely  and  compactly  with  each  other,  so  as  to  take  a small' 
space,  are  so  arranged  that  they  occupy  a large  one,  and  present 
a considerable  bulk. 

The  minute  anatomical  structure  of  bone  was  again  investigated^ 
by  Deutsch  in  1834,  and  by  Muller  and  Miescher  in  1836. 

The  former  observed  the  pores  or  tubules  of  Havers,  (canaliculi 
Haversiani)  to  be  surrounded  with  concentric  lamdlcE,  and  the  me- 
dullary canal  in  the  cylindrical  bones  to  be  inclosed  by  another 


BONE. 


431 


order  of  lamella,  and  the  same  canals  in  the  flat  bones  proceeding 
from  the  parallel  of  the  surface.  Tliese  tubules  he  describes  as 
crowded  and  passing  across  from  one  lamella  to  the  next.  He 
also  mentions  the  oblong  corpuscula,  which  have  been  discovered 
by  Purkinje  to  be  everywhere  dispersed  through  their  texture. 

In  many  circumstances,  the  observations  of  Muller  and  Mies- 
cher  agree.  Both  admit  the  existence  of  lamella,  of  corpuscula, 
and  of  canaliculi  o^ tubular  canals,  the  pores  of  Havers. 

The  lamella,  says  Miiller,  are  so  translucent,  that,  when  laid  on 
written  paper,  the  characters  may  be  easily  read  through  them. 
When  these  lamellae  are  examined  under  the  lens  on  a dark  ground, 
it  is  seen  that  the  whiteness  of  bones  depends  on  the  corpuscula, 
and  that  their  intermediate  substance  is  entirely  transparent. 

Lamina  or  lamella  are  not  observed  in  the  bones  of  infants. 
But  they  are  distinctly  seen  in  the  compact  tissue  of  the  cylindrical 
bones  of  adults,  in  which  they  form  the  external  surface  or  com- 
pact tissue.  Near  the  medullary  canal,  where  the  number  of  in- 
tersecting canaliculi  increases,  they  gradually,  and  at  length  com- 
pletely vanish. 

The  thickness  of  these  lamina  is  estimated  by  Deutsch  at 
part  of  an  inch.  This  Miescher  thinks  the  result  of  typographical 
error,  and  he  makes  them  ^l^gth  part  of  an  English  inch,  or  -0027 
of  one  line.  In  the  thigh-bone  of  the  ox,  in  which  the  lamina  may 
be  separated  into  lamella  much  more  easily  and  more  distinctly 
than  in  human  bones,  the  component  lamella  appeared  as  it  were 
to  be  separated  or  united  by  fibres  interposed  ; and  in  parts  where 
the  lamella  were  most  closely  united,  Miescher  observed  slender, 
tapering  fihrilla  following  the  longitudinal  direction,  of  a brown 
colour,  and  firm,  which,  throughout,  penetrated  the  lamina,  and 
which  he  regards  as  certainly  the  same  with  the  nails  or  claviculi 
of  Gagliardi,  and  the  fibres  described,  in  1818,  by  Medici.  The 
lamellae  may  be  divided  by  needles  into  several  very  slender /o/zbZa 
or  leaflets. 

The  canaliculi  are  found  in  all  the  compact  osseous  tissue,  and, 
in  general,  their  direction  follows  that  of  the  process  of  ossification 
in  the  foetus.  Thus,  in  the  cylindrical  bones,  they  proceed  from  the 
middle  of  the  shaft  to  the  articular  extremities ; and  in  the  frontal 
and  parietal  bones,  from  the  centre  to  the  circumference. 

The  interior  of  these  canals  is  cylindrical,  and  it  is  smallest  in 
those  near  the  surface ; conversely,  near  the  medullary  canal,  they 


432 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


become  larger,  so  that  they  may  be  three  or  four  times  more  ample 
than  those  at  the  compact  surface  of  the  hone.  The  intersection  of 
these  canals,  also  near  the  medullary  cavity  with  their  enlarged 
size,  produces  the  formation  of  cells,  which  communicate  with  se- 
veral of  the  canaliculi. 

The  wall  of  the  canaliculi  is  composed  of  from  10  to  15  con- 
centric lamellse,  and  is  from  jgoth  to  ^^gth  part  of  an  English  inch 
broad.  These  canals  contain  marrow  or  a substance  like  it. 

The  corpuscula^  which  were  known  to  Leewenhoeck,  but  have 
been  fully  examined  only  by  Purkinje,  Deutsch,  Miescher,  and 
Muller,  are  oblong  oval  bodies,  flattened,  and  pointed  at  each 
end,  situate  between  two  lamellce,  so  that  their  long  diameter  pre- 
serves an  oblique  direction  to  the  lamella.  They  are  observed  in 
bone  which  has  been  deprived  of  its  earthy  matter  by  acid,  like 
minute  specks  of  a brown  colour,  transparent  in  the  middle  and 
bounded  by  a distinct  opaque  line.  Their  size  varies.  From 
them  proceed  many  dark-coloured  striae,  so  that  they  present  the 
appearance  of  ovoidal  bodies  with  small  fibrils  or  roots  proceeding 
from  them.  Their  long  diameter  is  from  .0048  to  .0072  ; and 
their  transverse  diameter  from  .0017  to  .0030  of  one  line. 


These  bodies  are  formed  in  the  primary  or  ossifying  cartilage; 
around  them  ossification  takes  place ; and  it  appears  that  their  pre- 
sence is  of  great  importance  to  the  oi'iginal  formation  of  the  bone. 


When  these  corpuscula  are  examined,  by  a powerful  microscope, 
with  refracted  light,  they  appear  like  black  oblong  specks,  with  the 
dark  strice  proceeding  from  their  surface  in  all  directions,  but  most 
abundantly  from  their  lateral  regions.  When  they  are  examined 


by  reflected  light,  they  appear  like  bluish-white  specks  of  a milky 
colour,  with  the  stricB  of  the  same  colour  proceeding  from  them. 


of  much  inquiry.  When  laminae  of  bones  finely  polished  are  boil-  " 
ed  in  potass,  and  thereby  deprived  of  their  translucency,  the  cal- 
careous matter  of  the  part  formerly  translucent  adheres,  exactly  as 
if  the  structure  of  the  animal  matter  had  been  in  no  way  changed. 

In  alt  the  intermediate  spaces  the  substance  of  the  corpuscula  ap- 
pears finely  granulated ; and  the  white  grains  equal  nearly  the 
size  of  the  diameter  of  the  radiating  canals  of  these  bodies. 

Muller  thinks  it  merely  probable  that  these  corpuscula  may  be 
a sort  of  secreting  organs  to  deposit  osseous  matter  ; and  he  there-  j 
fore  is  disposed,  though  not  very  confidently,  to  term  them  organa 


What  the  nature  of  these  corpuscula  may  be,  has  been  a source 


BONE. 


433 


chalikophora,  or  earth-bearing  organs.  He  allows,  however,  that 
it  is  impossible  on  this  subject  to  speak  with  certainty. 

Miescher  states  the  following  conclusions  : Isf,  The  spongy  or 
cancellated  tissue  is  nothing  but  enlarged  canaliculL  2(f,  The 
medullary  canal,  as  to  formation  and  signification,  must  be  regard- 
ed as  the  union  of  such  canaliculi.  3d,  The  canals,  therefore,  sur- 
rounded by  concentric  lamellae,  and  containing  marrow,  furnished 
with  abundant  blood-vessels,  are  the  primary  form  of  the  osseous 
tissues  completed  by  growth.* 

In  these  results  there  is  nothing  new.  Indeed,  the  only  new 
fact  in  the  whole  is  the  existence  of  the  corpiiscula.  The  idea  of 
lamellcR  is  not  new.  Their  existence  was  maintained  by  Gagliardi, 
Havers,  Reichel,  Blumenhach,  and  Soemmering;  and  it  may  be 
doubted  if  the  opinion  be  well  founded. 

As  to  the  corpuscula,  they  are  stated  to  exist  in  the  primary  or 
ossifying  cartilage  or  callus ; and  it  is  very  probable  that  they  in 
some  manner  contribute  to  the  formation  of  bone,  as  it  is  even- 
tually observed  to  exist. 

Though  hone  has  been  submitted  to  analysis  by  many  eminent 
chemists,  the  results  hitherto  obtained  cannot  be  said  to  be  quite 
satisfactory.  The  most  complete  is  that  of  Berzelius,  who,  in  100 
parts  of  bone  from  the  thigh  of  an  adult,  gives  the  following  pro- 
portions: of  gelatine,  32.17;  blood-vessels,  1.13;  phosphate  of 
lime,  51.04  ; carbonate  of  lime,  11.30  ; fluate  of  lime,  2.00  ; phos- 
phate of  magnesia,  1.16  ; hydrochlorate  of  soda  and  water,  120. 

These  results  by  no  means  agree  with  those  obtained  by  Four- 
croy  and  Vauquelin,  who  found  neither  fluoric  acid  nor  phosphate 
of  magnesia,  but  discovered  oxides  of  iron  and  manganese,  silica? 
and  alumina,  in  bone.  The  statement  of  Berzelius  regarding  the 
presence  of  fluate  of  lime  has,  on  the  other  hand,  been  confirmed 
by  Dr  George  Wilson,  who  found  it  in  recent  bones  of  the  human 
body,  and  in  those  of  various  mamm.alia,  and  in  fossil  bones. 
Sulphate  of  lime,  which  was  found  in  the  experiments  of  Hat- 
chett, was  shown  by  Berzelius  to  be  formed  during  calcination. 

It  is,  however,  obvious  that  a little  more  than  a third  part  of 
bone  consists  of  animal  matter,  which  appears  to  be  either  entirely 
gelatine,  or  a modification  of  that  principle  ; and  that  the  remain- 
der, nearly  equal  to  two-thirds,  consists  of  earthy  matter,  which  is 
chiefly  phosphoric  acid  combined  with  lime.  From  the  experiments 
of  Dr  Rees  it  results  that  |-ths  are  earthy  matter ; and  |ths  are 

* De  Inflammatione  Ossium,  eorumque  Anatome  Generate.  Exercitatio  Anatomi- 
co  Pathologica.  Auctore  Friderico  Miescher,  Med,  et  Chirurgias  Doct.,  cum  Tabulia 
Quatuor  Aeneis.  Berolini,  1836.  4to. 


E e 


434 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


animal  matter.  Is  the  carbonic  acid  said  to  be  united  witii  lime 
also  not  a result  of  the  decomposition  of  the  animal  matter  ? The 
other  saline  substances  are  not  peculiar  to  bone,  but  being  common 
to  it  and  the  other  animal  tissues,  and  even  the  fluids,  may  be  sup- 
posed, without  much  injustice,  to  be  derived  from  the  blood  left  in 
the  bone  at  the  moment  of  death. 

The  cylindrical  bones  of  the  extremities  contain  more  earthy 
matter  than  those  of  the  trunk ; the  bones  of  the  upper  extremity 
contain  more  earthy  matter  than  the  corresponding  bones  of  the 
lower  extremity  ; and  the  bones  of  the  head  contain  considerably 
more  earthy  matter  than  the  bones  of  the  trunk.* 

It  is  most  difficult  to  say  what  is  the  nature  of  the  animal  matter 
of  bones.  At  one  time  it  was  presumed  to  he  cartilage  ; but  this 
appears  to  be  a mere  assumption,  derived  from  the  superficial  re- 
semblance which  it  bears  to  this  substance.  It  does  not  appear  to 
be  mere  gelatine  ; for  though  this  principle  is  obtained  in  quantity 
from  bone,  and  bones  are  economically  used  in  manufacturing  glue, 
they  do  not  furnish  the  same  proportion  of  jelly  as  tendon,  nor  are 
they  so  useful  in  making  soups,  as  was  once  paradoxically  and  ab- 
surdly enough  maintained  by  some  chemists.  It  is  probable  that 
the  gelatine,  as  we  have  already  stated,  is  under  a peculiar  modi- 
fication, or  combined  with  some  principle  which  is  not  well  under- 
stood. Is  there  no  albumen  in  this  animal  matter  ? The  sulphur 
formed  during  calcination  seems  to  show  that  there  is.  There  is 
no  fat  in  bones;  and  in  the  experiments  in  which  this  substance  has 
been  found,  it  is  evident  that  it  was  merely  marrow  which  had  been 
mingled  with  the  bones  employed,  or  which  had  not  been  removed. 

Though  bones  were  arranged  by  the  ancients  among  the  blood- 
less organic  substances,  they  receive  a considerable  proportion  of 
this  fluid,  and  injection  shows  them  to  be  highly  vascular.  In  early 
life,  especially,  these  vessels  are  numerous ; and  even  in  the  grown 
adult,  when  death  takes  place  by  strangulation  or  by  drowning,  the 
bones  are  found  to  be  naturally  well  injected.  In  old  age  the 
vessels  are  less  numerous,  but  they  are  larger.  From  the  capillary 
vessels  distributed  through  their  substance,  bones  derive  the  pale 
blue  or  light  pink  colour  by  which  the  healthy  bone  is  characterized. 
When  this  tint  becomes  intense,  it  indicates  inflammation  or  some 
morbid  state  of  the  vessels  of  the  bone.  When  it  is  lost,  and  the 
bone  assumes  a white  or  yellow  colour,  the  part  so  changed  is  dead. 

Anatomists  distinguish  three  orders  of  vessels  which  enter  the 
substance  of  bones ; the  first,  those  which  penetrate  the  bodies  of 

* On  the  Proportions  of  Animal  and  Earthy  Matter,  &c.  By  G.  0.  Rees,  M.  D. 
Mediso-Chirurgical  Transactions,  Vol.  XXI.  p.  406.  London,  1838. 


BONE. 


435 


long  bones  to  the  medullary  cavity,  (arterias  nutritice,  arterice  me- 
dullares ;)  the  second,  those  which  go  to  the  cellular  structure  of 
the  bone ; and  the  third,  those  which  go  to  the  compact  or  dense 
matter  of  the  bone.  This  view  is  only  partially  correct.  The  large 
vessels  termed  nutritious  certainly  proceed  chiefly  to  the  cavity  of 
the  bone,  and  are  distributed  in  the  medullary  membrane.  These, 
however,  are  not  the  only  vessels  which  proceed  to  this  part  of  the 
bone.  jFi'rsi,  I have  often  traced  several  large  vessels,  entering  not 
by  the  middle,  but  the  ends  of  the  long  bones,  into  the  loose  can- 
cellated texture,  and  actually  distributed  on  the  medulla  in  this  part 
of  the  bone.  In  dried  bones  also  the  canals  of  these  vessels  may 
be  demonstrated  extending  from  the  surface  to  the  body  of  the 
bone.  Secondly^  the  nutritious  vessels  are  not  constant ; and  when 
they  are  wanting,  those  of  the  ends  of  the  bone,  or  of  the  cancelli, 
are  much  larger  and  more  numerous  than  in  ordinary  circum- 
stances. The  communication  between  these  and  the  branches  of 
the  nutritious  vessels,  which  is  admitted  by  Bichat,  may  be  easily 
demonstrated.  The  third  order  of  vessels  are  those  which  may  be 
termed  periosteal^  in  so  far  as  they  consist  of  an  infinite  number  of 
minute  capillaries,  some  red,  some  colourless,  proceeding  from  the 
periosteum  to  the  bone,  and  contributing  to  maintain  the  connec- 
tion between  the  two.  The  short  bones  and  the  flat  bones,  which 
are  destitute  of  nutritious  arteries,  receive  blood  from  tbe  two  latter 
orders,  but  principally  from  the  periosteal  vessels.  In  the  skull 
these  vessels  are  often  highly  injected  in  apoplectic  subjects,  and  in 
persons  killed  by  drowning  or  strangulation. 

The  veins  of  bones  are  peculiar  in  their  arrangement.  The  nu- 
tritious artery  is  accompanied  by  a social  vein ; the  articular  and  pe- 
riosteal vessels  are  said  to  be  destitute  of  corresponding  venous  ves- 
sels. According  to  Dupuytren,  however,  minute  venous  capillaries 
arise  from  the  substance  of  the  osseous  tissue,  precisely  as  in  other 
tissues,  and,  uniting  in  the  same  manner,  form  twigs,  branches, 
and  trunks,  which  finally  terminate  in  the  neighbouring  veins. 

Lymphatics  are  not  found  in  the  substance  of  bones.  Bichat, 
however,  thinks  analogically,  that  nutrition  implies  exhalation  and 
absorption ; but  it  is  manifest  that  this  does  not  demonstrate  the 
existence  of  true  lymphatics.  Nerves  in  like  manner  have  not  been 
traced  into  this  substance.* 

To  complete  the  anatomical  history  of  bone,  it  is  requisite  to 
examine  shortly  the  marrow.  The  interior  of  the  long  bones  con- 

* On  these  points  see  Scarpa,  cZfi  Anatome  et  Pathnlogia  Ossium  Comment,  p.  38, 
&c.  ; and  Howship,  Med.  Chir.  Tr.  Vol.  VIII.  p.  66. 


436 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


tains  a notable  quantity  of  fat,  oleaginous  matter,  which  has  been 
long  known  under  the  name  of  marrow  (^[j^uiKog  Iht%,  medulla ;)  and 
a similar  substance,  though  in  much  smaller  quantity,  is  found  in 
the  loose  cancellated  tissue  of  the  flat  and  short  bones.  It  is  in  the 
first  situation  only  that  it  is  possible  to  examine  the  anatomical  cha- 
racters  of  this  substance.  It  is  sufficiently  similar  to  fat  or  animal  1 
oil  in  other  parts  of  the  body  to  lead  us  to  refer  it  at  present  to  that 
head.  In  other  respects,  its  chemical  qualities  have  not  been  much 
examined ; hut  an  analysis  by  Berzelius  shows  that  it  consists  ^ 
chiefly  of  an  oily  matter,  not  unlike  butter  in  general  properties. 

The  filaments,  blood-vessels,  albumen,  gelatine,  and  osmazome  found  *■ 
by  this  chemist  in  marrow,  are  to  be  regarded  as  derived  from  the  ^ 
filamentous  tissue  in  which  the  medullary  particles  are  deposited, 
and  by  no  means  to  be  arranged  with  it.  They  did  not  exceed  4 
parts  in  the  100.  The  medullary  membrane,  which  has  been  con-  1m 
sidered  as  an  internal  periosteum,  is  but  imperfectly  known.  There 
can  be  no  doubt,  however,  of  its  existence,  which  is  easily  demon- 
strated  by  opening  either  transversely  or  longitudinally  the  medul-  % 
lary  canal  of  a long  bone,  and  boiling  it  for  about  two  hours.  The  ; , 
marrow  then,  as  is  well  known  to  cooks,  drops  out ; and  it  will  be 
found  on  examination  to  be  deposited  in  the  interstices  of  a fila- 
mentous  net-work  of  animal  matter,  which  is  not  unlike  very  fine 
filamentous  or  cellular  tissue,  which  may  be  traced  not  only  into 
the  lattice-work  of  the  extremities,  but  into  the  longitudinal  canals  " 
of  the  cylindrical  bones.  It  is  traversed  by  blood-vessels,  which 
are  observed  to  bleed  during  amputation.  No  nerves  have  been 
found  in  it.  The  medullary  membrane,  in  short,  may  be  regarded 
as  an  extensive  net-work  of  very  minute  capillaries  united  by  deli- 
cate filamentous  tissue.  From  these  capillaries  the  marrow  is  de- 
posited as  a secretion. — (Mascagni,  Howship.) 

The  development  or  progressive  formation  of  the  osseous  system  I 
has  given  rise  to  many  interesting  researches  by  Kerckringius,  i 
Vater,*  Baster,!  Duhamel,:{;  Nesbitt,§  Haller,||  Dethleef,1[  Reichel, 
Albinus,**David,Troja,  Scarpa,  John  Hunter,!!  Senff,!!Howship,§§  | 

* De  Osteogenia  Natural!  et  Prseternaturali.  Haller,  Disput.  Anat.  Vol.  VI.  p.  227.  I 
t De  Osteogenia.  Haller,  Disp.  Anat.  Vol.  VII.  I 

J Alem.  tie  I’Academie  Royale,  1741-42,  &c.  i 

§ Human  Osteogeny,  &c.  By  Ro.  Nesbitt,  M.  D.  Lond.  1736.  I 

l|  Opera  Minora,  Tom.  II.  XXXIII.  p.  460.  , 

Dissert.  Ossium  Calli  generationem  exhibens.  Goett.  1753. 

Annot.  Anat.  et  Eikones  Os.  Foet.  Hum.  Lug.  Bat.  1763.  i 

f.(-  Medical  and  Chii-urgical  Transactions,  Vol.  II. 

:J;f.  Nonnulla  de  Incremento  Ossium,  &c.  Halle,  1781.  I 

§§  Medico-Chirurgical  Transactions,  Vol,  VI.  p.  263.  | 


BONE. 


437 


Meckel,*  Medici,  Serres,  Lebel,  Schultze,  Bedard,  and  Dutro- 
chet ; and  it  is  a proof  of  the  difficult  and  complicated  nature  of 
the  subject,  that  it  still  continues  to  give  rise  to  fresh  investigation. 
The  inquiry  naturally  resolves  itself  into  two  parts, — the  history  of 
the  process  of  ossification,  as  it  takes  place  originally  in  the  foetus 
and  infant,  and  the  history  of  its  progress  as  a process  of  repair 
when  bones  are  divided,  broken,  or  otherwise  destroyed  or  removed. 

From  the  first  formation  of  the  embryo  to  the  termination  of 
foetal  existence  and  thenceforth  to  the  completion  of  growth,  the 
bones  undergo  changes,  in  which  various  stages  may  be  distinguished. 
In  the  first  weeks  of  foetal  existence  it  is  impossible  to  recognize 
anything  like  hone ; and  the  points  in  which  the  bones  are  after- 
wards to  be  developed  consist  of  a soft  homogeneous  mass  of  ani- 
mal matter,  which  has  been  designated  under  the  general  name  of 
mucus.  Sometime  between  the  fifth  and  the  seventh  week,  in  the 
situation  of  the  extremities,  may  be  recognized  dark  opaque  spots, 
which  are  firmer  and  more  solid  than  the  surrounding  animal  mat- 
ter. About  the  eighth  week,  the  extremities  may  he  seen  to  consist 
of  their  component  parts,  in  the  centre  of  each  of  wdiich  is  a cylin- 
drical piece  of  bony  matter.  Dark  solid  specks  are  also  seen  in 
the  spine,  corresponding  to  the  bodies  of  the  vertehrse ; and  even 
the  rudiments  of  spinous  processes  are  observed  in  the  shape  of  mi- 
nute dark  points.  In  the  hands  and  feet  rings  of  bones  are  seen 
in  the  site  of  the  metacarpal  and  metatarsal  bones.  All  the  joints 
consist  of  a semi-consistent  jelly-like  matter  liberally  supplied  by 
blood-vessels.  At  ten  weeks  the  cylinders  and  rings  are  increased 
in  length,  and  are  observed  to  approach  the  jelly-like  extremities, 
which  are  acquiring  the  consistence  of  cartilage,  and  when  divided 
present  irregular  cavities.  At  the  same  time  the  parts  forming  the 
head  are  highly  vascular ; and  between  the  membranes  are  depo- 
sited minute  points  of  bony  matter,  proceeding  in  rays  from  a centre, 
which,  however,  is  thinner  and  more  transparent  than  the  margin 
or  circumference — (Howship.) 

Between  thirteen  weeks  and  four  months  the  cavities  in  the  jelly- 
like  cartilaginous  matter  receives  injection.  The  membranes  of  the 
head  are  highly  vascular,  transmitting'  their  vessels  through  the  in- 
tervals of  the  osseous  rays,  which  are  occupied  abundantly  by  stiff, 
glairy,  colourless  mucilaginous  fluid. 

In  the  seventh  month,  the  bony  cylinder  of  the  thigh-bone  and 
its  epiphyses  contain  canals  perceptible  to  the  microscope.  In  the 

* Journal  Complementaire,  Tome  II.  p.  211. 


438 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


head,  the  bones  are  proceeding  to  completion  ; the  pericranium  and 
dura  mater  are  highly  vascular ; and  a quantity  of  reddish  semi- 
transparent jelly  between  the  scalp  and  the  skull,  which  contained 
numerous  minute  vessels,  Mr  Howship  regards  as  the  loose  cellu- 
lar state  of  the  foetal  pericranium.  This  is,  however,  doubtful. 
The  cylindrical  bones  have  at  this  period  no  medullary  cavity,  but 
present  in  their  interior  a loose  bony  texture. 

Between  the  seventh  and  eighth  months,  in  a foetus  ten  inches 
long,  I find  the  humerus  consisting  of  a cylinder  of  bone  placed 
between  two  brownish  firm,  jelly-like  masses,  which  correspond  to 
the  epiphyses,  enclosed  by  periosteum,  which  adheres  loosely  by 
means  of  filamentous  and  vascular  productions.  The  radius  is- a 
thin  bony  rod,  also  between  two  jelly-like  epiphyses.  The  ulna  is 
still  thinner,  more  slender  and  flexible,  and  even  compressible. 
The  interosseous  ligament  is  a continuous  duplicature  of  the  peri- 
osteum. The  metacarpal  bones  are  much  as  before,  only  larger. 
The  hands  and  fingers  are  complete ; but  the  phalanges  consist  of 
minute  semi-hard  grains,  enclosed  in  periosteum,  which  forms  a ge- 
neral sac  to  them,  and  to  the  intermediate  connecting  parts.  The 
middle  and  unguinal  phalanges  can  scarcely  be  called  osseous.  The 
femur,  like  the  humerus,  is  an  osseous  cylinder  between  two  jelly- 
like  epiphyses,  enveloped  in  loosely  adhering  periosteum.  The 
tibia  and  fibula  like  the  radius  and  ulna.  The  metatarsal  bones 
are  cylindrical  pieces,  firm,  but  not  very  hard.  The  first  phalanx 
of  the  toes  is  complete ; the  other  two,  though  the  toes  are  fully 
formed,  are  much  of  the  consistence  of  cartilage.  The  carpal  and 
tarsal  hones  are  in  the  state  of  the  epiphyses,  but  of  a gray  colour. 

In  this  state  of  the  osseous  system,  the  periosteum,  which  is  con- 
tinuous, and  appears  to  make  one  membrane  with  the  capsular  li- 
gaments and  the  deep-seated  portions  of  the  fascia,  adheres  to  the 
bone  chiefly  by  arteries  and  filamentous  productions ; and  so  loose 
is  this  connection,  that  a probe  may  be  inserted  beneath  it,  and 
carried  round  or  inwards,  unless  where  these  connections  are  situate. 
Another  point  where  the  periosteum  adheres  firmly  is  at  muscular 
insertions.  Thus  it  adheres  to  the  humerus  most  firmly  at  the  inser-  ? 
tion  of  the  deltoid,  and  to  the  femur  at  that  of  the  glutcBus ; and  at 
these  parts  the  bone  is  already  rough. 

In  the  vertebral  column  the  bodies  of  the  vertebrae  and  the  spi- 
nous plates  are  formed ; and  minute  specks  are  beginning  in  the 
site  of  the  transverse  processes. 


BONE. 


439 


III  the  skull,  the  parietal  bones  are  well-formed  shells  of  bone, 
though  very  deficient  at  the  mesial  plane,  the  anterior  margin,  and 
the  upper  anterior  angle.  The  pericranium  is  distinctly  membra- 
nous and  vascular;  and  the  red  jelly-like  fluid  noticed  by  Mr  How- 
ship  is  exterior  to  this  membrane. 

At  the  period  of  birth,  the  cylindrical  bones  contain  tubular 
canals  filled  with  a colourless  glairy  fluid,  and  terminating  in  the 
surface  of  ossification.  As  the  bones  previous  to  this  period  are 
homogeneous,  and  contain  no  distinct  medullary  cavity,  but  present 
in  their  interior  a soft  or  loose  bony  texture,  it  is  reasonable  to  sup- 
pose that  the  development  of  the  longitudinal  canals  is  connected 
with  the  formation  of  the  medullary  cavity.  At  birth  in  the  femur 
may  be  distinguished  a medullary  cavity  beginning  to  be  formed, 
about  half  a line  broad,  but  still  very  imperfect. 

After  birth  the  two  processes  of  the  formation  of  tubular  canals 
and  medullary  cavity  go  ou  simultaneously ; and  at  the  same  rate 
nearly  the  outer  part  of  the  cylindrical  bones  acquires  a more  dense 
and  compact  appearance.  The  epiphyses,  also,  which  are  in  the 
shape  of  grayish  jelly-like  masses,  begin  to  present  grains  and  points 
of  bone.  Preliminary  to  this,  Mr  Howship  represents  them,  while 
still  cartilaginous,  as  penetrated  by  canals  or  tubes,  which  gradually 
disappear  as  ossification  proceeds.  The  carpal  and  tarsal  bones  ap- 
pear to  observe  the  same  course  in  the  process  of  ossification. 

In  the  bones  of  the  skull,  however,  a difiereut  law  is  observed. 
The  osseous  matter  is  originally  deposited  in  linear  tracts  or  fibres, 
radiating  or  diverging  from  certain  points  termed  points  of  ossifi- 
cation. Each  bone  is  completed  in  one  shell  without  diploe  or  dis- 
tinguishable table.  Afterwards,  when  they  are  completed  late- 
rally, or  in  the  radiating  direction,  the  cancellated  arrangement  of 
the  diploe  begins  to  take  place,  apparently  in  the  same  manner,  in 
which  the  medullary  cavity  and  compact  parts  of  the  long  bones 
are  formed. 

It  has  been  generally  supposed  that  the  formation  of  cartilage  is 
a preliminary  step  to  that  of  bone.  This,  however,  seems  to  be  a 
mistake  arising  from  the  circumstance,  that  cartilage  is  often  ob- 
served to  be  converted  in  the  living  body  into  bone.  Neither  in 
the  long  nor  in  the  flat  bones  is  anything  like  cartilage  at  any  time 
observed.  The  epiphyses,  indeed,  present  something  of  the  con- 
sistence of  cartilage,  but  it  has  neither  the  firmness  nor  the  elasti- 
city of  that  substance.  It  is  a concrete  jelly,  afterwards  to  be  pe- 


440 


GENERAL  AND  Px\.THOLOGlCAL  ANATOMY. 


netrated  by  calcareous  matter.  The  flat  bones  are  from  the  first 
osseous ; and  though  their  margins  are  soft  and  flexible,  in  conse- 
quence of  their  recent  formation  and  moist  state,  they  have  still  a 
distinct  osseous  appearance  and  arrangement,  and  bear  no  resem- 
blance to  cartilage.  In  short,  true  bone  seems  never  at  any  period 
of  its  growth  to  be  cartilaginous. 

The  period  at  which  ossification  may  be  said  to  be  completed 
varies  doubtless  in  different  individuals.  It  may  be  said  to  be  in- 
dicated by  the  completion  of  themedullary  canal,  by  the  ossification 
of  the  epiphyses,  and  their  perfect  union  with  the  osseous  cylinder, 
{(liaphysis.)  The  first  circumstance  is  always  indefinite.  The  two 
latter,  though  more  fixed,  are  still  liable  to  great  variation.  The 
epiphyses  are  rarely  united  before  the  age  of  14  or  15;  and  they 
may  continue  detached  till  the  20th  or  21st  year.  I preserved  the 
greater  part  of  the  skeleton  of  a man,  who  was  known  to  be  about 
28,  and  in  whose  bones  the  epiphyses  were  imperfectly  united, 
and  many  had  dropped  off.  In  general,  however,  they  begin  to 
unite,  or  to  be  knit,  as  is  said,  between  the  15th  and  20th  years. 

Little  doubt  can  be  entertained  that  the  main  agents  of  original 
ossification  are  the  periosteum  and  the  periosteal  arteries.  The 
proofs  of  this  inference  are  manifest.  The  formation  of  bone  has 
never  been  ascribed  but  to  the  vessels  of  two  agents, — the  perios- 
teum and  the  medullary  membrane.  That  the  latter  cannot  be  con- 
cerned in  the  production  of  bone  in  the  foetus  must  be  inferred  from 
the  fact,  that  at  that  period  it  cannot  be  said  to  have  existence. 
To  the  periosteum,  therefore,  and  its  vessels  must  be  ascribed  the 
process  of  foetal  ossification.  Of  this  a cumulative  proof  may  be 
found  in  the  circumstance,  that  the  periosteum  adheres  more  firmly 
at  the  ends  than  the  middle  of  the  bones  ; and  that  the  pericranium 
and  dura  mater,  which  perform  the  part  of  periosteum  to  the  bones 
of  the  skull,  are  visibly  concerned  in  the  formation  and  successive 
enlargement  of  these  bones.  But  though  the  periosteal  vessels  are 
the  main  agents  of  ossification  originally,  there  is  reason  to  believe 
that  the  medullary  vessels  contribute  to  its  growth  and  nutrition 
after  it  is  formed.  This  may  be  inferred  from  the  phenomena  of 
fractures,  of  diseases  of  the  bones,  and  of  those  experiments  in  which 
the  medullary  membrane  is  injured.  The  periosteum,  however, 
does  not  act  by  ossification  of  its  inner  layers,  as  Du  Hamel,  misled 
by  a false  analogy  between  the  growth  of  trees  and  bones,  laboured 
to  establish.  This  leads  naturally  to  the  examination  of  the  ijhe- 


BONE. 


441 


nomena  of  ossification  as  a process  of  repair.  This,  however,  is  in- 
troduced more  properly  under  the  next  section. 

The  teeth,  as  a variety  of  bone,  demand  attention.  Every  tooth 
consists  of  two  hard  parts ; one  external,  white,  uniform,  somewhat 
like  ivory,  the  other  internal,  similar  to  the  compact  structure  of 
bone. 

The  first,  which  is  named  enamel,  is  seen  only  at  the  crown  of 
the  tooth,  the  upper  and  outer  part  of  which  consists  of  this  sub- 
stance. It  is  white,  very  close  in  texture,  perfectly  uniform  and 
homogeneous,  yet  presenting  a fibrous  arrangement.  Extending 
across  the  summit  of  the  tooth  in  the  manner  of  an  incrustation,  it 
is  thick  above,  and  diminishes  gradually  to  the  root,  where  it  dis- 
appears. This  fact  is  demonstrated  by  macerating  a tooth  in  dilute 
nitric  acid,  when  the  bony  root  becomes  yellow,  while  the  crown 
remains  white. 

The  enamel  is  not  iujectible,  and  is  therefore  believed  to  be  in- 
organic. It  is  also  filled  and  broken  without  being  reproduced ; 
nor  does  it  present  any  of  the  usual  properties  which  distinguished 
organized  bodies.  The  piercing  sensation  which  is  communicated 
through  the  tooth  from  the  impression  of  acids  seems  to  depend  on 
the  mere  chemical  operation,  and  not  on  the  physiological  effect. 
Upon  the  whole,  the  enamel  is  to  be  viewed  as  the  result  of  a pro- 
cess of  secretion  or  deposition,  but  as  inorganic  entirely. 

The  bony  part  of  the  tooth  is  the  root  and  that  internal  part 
which  is  covered  on  the  sides  and  above  by  the  enamel.  It  con- 
sists of  close-grained  bony  matter,  as  dense  as  the  compact  walls  of 
the  long  bones,  or  the  petrous  portion  of  the  temporal  bone.  The 
fibres  which  are  said  to  be  seen  in  it  are  exactly  of  the  same  nature 
as  those  in  bone. 

In  the  interior  of  the  bony  part  of  each  tooth  is  a cavity  which 
descends  into  the  root,  and  communicates  at  its  extremity  with  the 
outer  surface  by  openings  corresponding  with  the  number  of 
branches  into  which  the  root  is  divided.  This  cavity,  which  is 
larger  in  young  or  newly  formed  teeth,  and  small  in  those  which 
are  old,  contains  a delicate  vascular  membrane,  which  has  been 
named  the  pulp  of  the  tooth.  It  is  best  seen  by  breaking  a recent 
tooth  by  a smart  blow  with  a hammer,  when  the  soft  pulpy  mem- 
brane may  be  picked  out  of  the  fragments  by  the  forceps.  It  then 
appears  to  be  a membranous  web  with  two  surfaces,  an  exterior 
adhering  to  the  bony  surface  of  the  dental  cavity  by  minute  vessels; 


442 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  other  interior,  free,  and,  so  far  as  can  be  determined  of  a body 
so  minute,  resembling  a close  sac. 

The  development  and  growth  of  the  teeth  is  a process  of  much 
interest. 

At  what  time  the  first  rudiments  of  teeth  appear  seems  not  to 
be  determined  with  accuracy.  In  the  foetus,  between  tbe  seventh 
and  eighth  month,  I can  merely  distinguish  in  the  centre  of 
the  vascular  membrane  of  the  alveolar  cavity  a minute  firm  body 
like  a seed.  I have,  however,  seen  the  crowns  of  teeth  formed  in 
foetuses,  which  I have  reason  to  believe  had  not  attained  the  seventh 
month.  But  whatever  may  be  the  exact  period,  the  process  is 
nearly  as  follows. 

As  the  bones  of  the  upper  and  lower  jaw  are  in  the  process  of 
formation  between  the  third  and  fifth  months,*  cavities  at  their 
lower  and  upper  margins  are  gradually  formed  by  the  growth  of 
the  osseous  plates,  which  afterwards  form  the  alveoli.  As  these 
cavities  are  formed,  they  are  lined  by  a large,  soft,  membranous, 
vascular  sac,  which,  in  the  manner  of  a serous  membrane,  consists 
of  two  divisions,  one  lining  the  alveolus.,  the  other  folded  within 
that,  and  forming  a closed  cavity.  In  the  inside  of  this  cavity  the 
process  of  dentition  commences  some  time  between  the  fifth  and 
seventh  month,  by  the  deposition  of  matter  from  the  vessels  at  the 
lowest  point  of  the  alveolar  division  of  the  sac.  This  matter  is  to 
constitute  the  crown  of  the  tooth,  which  is  invariably  formed  first. 
After  the  deposition  of  the  first  portions,  these  are  pushed  upwards 
by  tbe  addition  of  successive  layers  below  them,  and  necessarily 
carry  the  inflected  part  of  the  sac  before  them.  As  this  process  of 
deposition  advances,  the  tooth  gradually  fills  the  sac,  and  rises  till 
it  reaches  the  level  of  the  alveolar  margins.  If  a tooth  be  examined 
in  situ,  near  the  period  of  birth,  it  is  found  to  consist  of  the  crown, 
with  portions  of  enamel  descending  on  every  side,  and  forming  a 
cavity  in  which  a cluster  of  blood-vessels,  proceeding  from  the  sac, 
is  lodged. 

After  the  enamel  has  been  deposited  the  bone  begins  to  be 
formed ; and  as  this  process  advances,  the  tooth  is  still  forcibly 
tbrust  upwards  by  the  addition  of  matter  to  its  root.  When  the 
latter  is  well  completed,  the  vessels  become  smaller  and  less  abun- 
dant ; until,  when  the  tooth  is  perfect,  they  shrink  to  a mere  mem- 
brane, which  lines  the  cavity  of  the  tooth,  and  still  maintains  its 
* Fourth  and  Fifth,  Bichat,  p.  93,  Tome  iii. 


BONE. 


443 


original  connection  with  the  alveolar  membrane,  by  the  minute 
vascular  production  which  enters  the  orifice  or  orifices  of  the  root. 

Physiological  authors  have  thought  it  important  to  mark  the 
period  at  which  the  teeth  appear  at  the  gums ; and  in  general  this 
takes  place  about  the  sixth  or  seventh  month  after  birth.  This 
mode  of  viewing  the  process  of  dentition,  however,  gives  rise  to 
numberless  mistakes  on  the  period  of  teething.  The  process,  as 
we  see,  commences  in  the  early  period  of  foetal  existence ; and  the 
time  at  which  they  appear  above  the  gums  varies  according  to  the 
progress  made  in  the  womb.  In  some  the  process  is  rapid ; in 
others  it  is  tardy ; and  even  the  fabulous  stories  of  Richard  III. 
and  Louis  XIV.  may  be  understood  physiologically,  without  the 
aid  of  the  marvellous.  Grenerally  speaking,  the  crown  is  com- 
pleted at  the  period  of  birth ; and,  according  as  the  formation  of  the 
root  advances  with  rapidity  or  slowly,  dentition  is  early  or  late. 

What  is  here  described  is  tbe  process  of  the  formation  of  the  first 
or  temporary  set  of  teeth,  which  consist,  it  is  well  known,  of  20. 
In  that  of  the  second  set  the  same  course  is  observed.  In  the  same 
manner  is  observed  a row  of  follicular  sacs,  though  not  exactly  in 
the  original  alveoli ; in  the  same  manner  deposition  begins  at  the 
bottom  of  the  free  surface  of  the  sac  by  the  formation  of  the  crown ; 
and  in  the  same  manner  the  crown  is  forcibly  raised  by  the  succes- 
sive accretion  of  new  matter  to  its  base.  The  moment  this  process 
commences,  a new  train  of  phenomena  takes  place  with  the  primary 
teeth.  The  follicular  sacs  of  the  new  or  permanent  teeth  are  libe- 
rally supplied  with  vessels  for  the  purpose  of  nutrition  ; and  as  these 
blood-vessels  increase  in  size,  those  of  the  temporary  teeth  dimi- 
nish ; and  the  supply  of  blood  being  thus  cut  off,  the  latter  undergo 
a sort  of  natural  death.  The  roots  which,  as  being  last  formed,  are 
not  unfrequently  incomplete,  now  undergo  a process  of  absorption ; 
and  the  tooth  drops  out  in  consequence  of  the  destruction  of  it& 
nutritious  vessels.  Some  authors  have  ascribed  this  expulsion  to 
pressure,  exercised  by  the  new  tooth.  They  forget,  however,  that 
before  tbe  new  tooth  can  exert  any  pressure,  it  must  be  in  some 
degree  formed ; and  to  this  a vascular  system  is  indispensable. 

Tbe  increased  number  of  the  teeth  when  permanent,  the  enlarge- 
ment of  the  jaws,  and  the  consequent  expansion  of  the  face,  though 
interesting,  are  foreign  to  the  present  inquiry. 

Another  part  of  the  osseous  system  requiring  notice  are  the  sesa- 
moid bones.  These  derive  their  name,  it  is  well  known,  from  their 


444 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


minuteness,  (^ariaaiMri,  a grain,)  most  of  them,  excepting  the  knee- 
pan,  being  of  the  size  of  a grain  or  pea.  They  are  confined  to  the 
extremities,  and  are  situate  chiefly  in  positions  in  which  they  give 
points  of  support  to  the  tendons  of  the  flexor  muscles.  (Tendons 
of  the  gemelli,  tibialis  posticus,  peronccus  largus,  &c.)  The  pecu- 
liarity of  these  bones  is,  that  they  are  formed  invariably  in  the  sub- 
stance of  fibrous  organs,  as  tendons  in  the  case  of  the  knee-pan  and 
the  sesamoid  bones  of  tbe  gemelli,  tibialis  posticus,  and  peronccus  1.  ; 
or  ligaments  in  tbe  case  of  those  situate  between  the  metacarpo-pha- 
langeal  and  metatarso -phalangeal  articulations.  With  this  pecu- 
liarity their  mode  of  ossification  corresponds.  At  first  albuminous 
or  fibro-albuminous,  in  process  of  time  they  are  penetrated  by  cal- 
careous matter,  and  present  an  osseous  texture,  which,  however,  is 
much  less  firm  than  that  of  genuine  bones.  The  period  at  which 
this  deposition  commences  and  is  completed  varies  in  different  indi- 
viduals ; and  hence,  scarcely  in  any  two  persons  of  the  same  age  is 
the  number  of  sesamoid  bones  tbe  same.  Though  tbe  patella  may 
be  ossified  at  the  20th  year,  the  minute  sesamoid  bones  are  some- 
times not  formed  before  the  30th  or  even  the  40th.  In  the  patella, 
when  ossified,  we  find  a medullary  organ.  But  it  is  uncertain 
whether  the  others  acquire  this  mark  of  osseous  character.  These 
bones  resemble  the  epiphyses  in  uniting,  when  divided,  by  fibro- 
albuminous  matter. 


Section  II. 

Osteitis  ; Inflammatio. — Though  all  practical  authors  admit  that 
bones  may  be  inflamed  either  spontaneously,  or  in  consequence 
of  injury,  yet  it  is  remarkable  that  none  have  communicated  any 
precise  idea  of  this  process ; and  while  they  admit  it  as  a patholo- 
gical fact,  they  have  too  often  lost  sight  of  it  in  one  or  more  of 
the  changes  to  which  it  gives  rise.  To  Mr  Howship  we  are  in- 
debted for  the  first  attempt  to  determine  with  precision  the  anato- 
mical characters  and  pathological  nature  of  this  process. 

It  may  at  first  sight  seem  doubtful  whether  genuine  bone  is  sus- 
ceptible of  such  a process  as  inflammation.  For  though  a bone 
constituted  as  already  described  is  doubtless  an  organized  substance, 
and  therefore  liable  to  the  actions  of  organized  bodies,  yet  whether 
a particle  of  completed  bone,  as  in  the  compact  parts  of  the  cylin- 
drical bones,  becomes  itself  the  seat  of  inflammation,  may  seem 

3 


BONE. 


445 


questionable.  The  morbid  process,  however,  to  which  the  actual 
bony  particles  may  not  be  competent,  the  membranous  covering  and 
the  vascular  filamentous  penetrating  web,  are  unquestionably  power- 
ful agents  in  efiecting.  In  short,  while  bone  as  a secretion  is  almost 
passive  in  its  morbid  relations,  we  observe  it  obeying  the  slightest 
infiuence  of  the  periosteum  and  its  vessels  on  the  one  hand,  and 
those  of  its  medullary  system  on  the  other. 

Having  premised  these  remarks,  it  is  to  be  observed  that  infiam- 
mation  occurring  in  bone  may  assume  various  forms. 

1.  Adhesive  Inflammation. — Of  these  the  simplest  is  that  which 
takes  place  in  the  process  of  union  after  fractures, — the  healthy  ossi- 
flc  inflammation  of  Mr  Hunter,  a variety  of  the  adhesive.  In  this 
three  distinct  stages  are  enumerated.  In  the  first,  effusion  of  blood 
from  the  periosteal  vessels  into  its  substance,  and  from  the  medul- 
lary vessels  into  the  fracture,  is  after  coagulation  followed  by  eflru- 
sion  of  a colourless  viscid  fluid,  which  also  coagulates  into  a jelly. 
(J.  Hunter,  Bichat,  Howship,  &c.)  In  the  second,  the  soft  parts, 
and  especially  the  periosteum,  become  hot,  red,  swollen,  and,  in 
short,  are  in  a state  of  inflammation.  ^ (Du  Hamel,  Howship,  &c.) 
If  at  this  time  the  fracture  be  examined,  the  periosteal  and  medul- 
lary arteries  at  the  line  of  fracture  are  large,  numerous,  and  are 
seen  emitting  vessels  into  the  coagulated  blood  and  lymph  efiused 
beneath  the  periosteum,  and  from  the  broken  ends,  and  converting 
them  into  organized  masses,  sometimes  distinct  like  granulations, 
sometimes  irregularly  continuous.  This  substance,  which  is  of  a 
reddish-gray  colour,  and  of  the  consistence  of  firm  jelly,  is  what  is 
named  callus.  The  third  stage  may  be  distinguished  by  the  ap- 
pearance of  osseous  points  which  now  begin  to  be  deposited  from 
the  new  vessels,  which  penetrate  from  the  periosteum  and  medul- 
lary filaments  to  the  callus.  As  the  arterial  action  advances,  these 
osseous  points  extend  from  the  broken  surface  and  coalesce.  The 
exterior  swelling  at  the  same  time  diminishes  and  disappears ; the 
periosteum  falls  to  its  natimal  size  and  its  ordinary  rate  of  vascu- 
larity ; the  medullary  canal  is  restored  in  greater  or  less  perfec- 
tion ; and  the  broken  portion  of  bone  after  some  time  recovers  the 
same  organization  and  firmness  nearly  which  it  originally  possessed. 
Instead  of  the  longitudinal  canals  which  are  found  in  compact 
healthy  bone,  however,  the  renewed  part  presents  a series  of  irre- 
gular cavities,  varying  in  size  and  direction,  and  which  contain  a 
vascular,  filamentous,  medullary  web.  (Howship.)  According  to 


446 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Mr  John  Bell  it  remains  for  years  more  vascular  than  the  con- 
tiguous bone.*  According  to  Howship  it  possesses  a larger  propor- 
tion of  animal  matter,  f 

In  some  instances  of  fracture  union  is  not  accomplished  in  this 
perfect  manner ; but  is  effected  merely  by  a fihro-albuminous  cica- 
trix, which  unites  the  fragments  loosely.  This  is  observed  espe- 
cially in  fractures  of  the  neck  of  the  thigh-bone,  (Bell,  Desault, 
Cooper,  Howship;)  of  the  knee-pan,  (Camper,  Callisen;)of  the 
olecranon,  and  other  parts  consisting  of  loose  cancellated  structure. 
Upon  the  reasons  of  this  physiologists  are  not  agreed.  By  some  it 
is  ascribed  to  defect  of  periosteum,  as  in  the  neck  of  the  thigh-bone 
(A.  C.  Hutchinson  ;)  by  others  it  is  attributed  to  inefficient  nutri- 
tion in  the  part  broken  off,  which  is  then  certainly  less  freely  sup- 
plied by  blood-vessels.  (J.  Bell,  Sir  A.  Cooper.) 

Further,  in  fractures  in  which  there  is  much  contusion  and  com- 
minution, and  especially  where  it  is  complicated  by  a communicat- 
ing wound  of  the  soft  parts,  reunion  is  rarely  complete.  The  sup- 
purative inflammation  which  then  succeeds  precludes  the  adhesive 
and  ossific,  and  generally  renders  the  latter  imperfect  or  entirely 
abortive.  In  such  circumstances  more  or  less  of  the  bone  dies,  and 
is  thrown  off  in  dead  splinters.  In  some  instances  even  necrosis 
may  be  produced,  as  is  exemplified  in  compound  fractures  produced 
by  gunshot. 

Even  in  simple  fracture  may  occur  a variety  of  incomplete  union. 

In  some  subjects,  in  whom  the  fragments  have  been  badly  applied, 
in  whom  they  have  been  often  moved,  or  in  whom  the  vessels  are 
inadequate  to  assume  the  ossific  action,  though  blood  and  lymph 
are  effused  from  the  periosteum  and  medullary  vessels,  and  under-  ^ 
go  coagulation,  adhesion  is  only  partial  and  imperfect.  It  is  not  fl 
penetrated  by  vessels  so  as  to  become  organized ; or  those  vessels 
are  rent  asunder  by  repeated  motions.  Under  such  circumstances,  H 
the  intermediate  substance,  instead  of  acquiring  solidity,  and  be-;^ 
coming  penetrated  by  bone,  is  partly  absorbed ; while  the  broken  ^ 
ends  are  converted  into  a secreting  surface,  which  discharges  se-T® 

* Principles  of  Surgery,  Vol.  I.  p.  507.  Disc.  12.  “ Having  cut  off  the  limb  of  a sol-  H 
dier  whose  limb  had  been  broken  in  America  twelve  years  before,  I found  upon  in-  ® 
jecting  the  bone,  that  while  the  bone  itself  received  the  red  colour  of  the  injection  ,, 
pretty  freely,  the  callus,  which  goes  in  a zig-zag  form,  joining  together  the  several  ends 
and  points  of  a very  oblique  fracture,  was  very  singularly  red.” 

f Experiments  and  Observations,  &c.  By  J.  Howship.  Med.  Chir.  Trans.  Vol.  IX. 
p.  143. 


BONE. 


447 


rous,  purulent  or  sero-purulent  fluid  in  small  quantity.  This  forms 
what  is  false  joint. 

In  the  pregnant,  or  persons  labouring  under  scurvy,  and  in  those 
affected  with  the  constitutional  symptoms  of  syphilis,  fracture  is  not 
united  by  bony  union. 

2.  Diastasis. — Next  to  fracture  may  be  placed  detachment  or 
disunion  of  the  epiphyses,  {diductio  epiphysium.)  In  young  sub- 
jects, while  the  epiphyses  are  still  imperfectly  united  to  the  diapTiy- 
sis,  this  may  occur,  in  consequence  of  forcible  stretching,  or  injury 
of  the  bone.  In  this  manner  it  is  noticed  by  Palfyn,  Reichel,*  Wil- 
mer,t  and  others.  Reichel  saw  it  in  the  humerus,  and  Wilmer  in 
the  tibia.  I have  seen  it  in  the  humerus  and  in  the  femur,  in  which 
chiefly  it  occurs.  Sometimes  it  may  be  traced  to  injudicious  efforts 
by  bone-setters  in  pulling  a thigh-bone  supposed  to  be  dislocated. 
It  is  liable  to  be  confounded  with  fracture  of  the  neck  of  the  thigh- 
bone. If  not  disturbed,  the  injury  is  repaired  by  union  either  in 
the  ordinary  manner,  or  with  more  or  less  extensive  ossification  of 
the  neighbouring  parts,  causing  generally  stiff-joint.  Consecutive 
disunion  of  an  epiphysis  may  happen  in  mollities  ossium  and  in  spi- 
na ventosa.  (Trioen,  Reichel.) 

The  variety  of  disunion  now  mentioned  is  generally  confined  to 
the  epiphysis  of  one  bone.  A more  general  disunion,  however,  oc- 
curring in  most  of  the  epiphyses  of  the  skeleton,  may  take  place  in 
scurvy.  This  was  remarked  especially  in  the  scorbutic  epidemic  of 
Paris  1743,  and  has  since  been  occasionally  seen.  (Lind.)  Inspec- 
tion shows  that  the  bones  are  penetrated  by  bloody  extravasation, 
— that  the  vessels  are  relaxed  and  atonized, — and  that  nutritious 
deposition  is  suspended.  This  scorbutic  diduction,  which  depends 
on  a disease  affecting  the  whole  system,  may  be  removed  by  the 
same  means  which  remove  that  morbid  condition.  Too  often,  how- 
ever, it  takes  place  in  that  stage  of  the  disease  in  which  recovery 
is  impossible. 

3.  I have  above  stated  that  it  may  be  justly  questioned  whether 
bone  itself  undergoes  tlie  organic  process  of  inflammation.  Most 
of  the  facts  hitherto  collected,  when  well  investigated,  favour  the 
inference,  that  the  inflammatory  conditions  of  bone  are  to  be  re- 
ferred to  inflammation  taking  place  either  in  the  periosteum ; or 
the  tomentose  medullary  web ; or,  finally,  in  the  articular  synovial 

* M.  Georgii  Ch.  Reichel,  de  Epiphysium  ab  Ossium  Diaphysi  Diductione.  Sandi- 
fort  Thesaur.  Vol.  I.  p.  1. 

f Cases  and  Remarks,  &c.  Lend.  1779.  P.  228. 


448 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


membrane  or  cartilage ; and  most  of  the  morbid  states  observed  by 
authors  in  bone  may  be  traced  to  some  variety  or  degree  of  inflam- 
mation in  one  or  more  of  these  textures. 

a.  "When  the  periosteum  becomes  inflamed,  one  of  several  effects 
may  follow. 

a.  It  may  induce  effusion  of  coagulable  lymph  into  its  substance, 
or  between  that  and  the  bone, — constituting  simple  node,  and  the 
tumour  termed  gumma* 

(3.  By  a modification  of  this  action  it  may  effuse  lymph,  which 
afterwards  becomes  ossified, — constituting  the  ossi/ic  node  of  Hun- 
ter and  Howship,  or  simply,  osseous  node,  (periostosis.)  This  ap- 
pears in  the  form  of  loose  bony  masses,  plates,  or  scales,,  on  the 
surface  of  such  cylindrical  bones  as  the  tibia  and  ulna^  which  are, 
nevertheless,  quite  natural.  In  some  instances  this  osseous  node 
appears  to  consist  in  ossification  of  the  inner  part  of  a circular  area 
of  inflamed  periosteum.  In  both  cases,  instead  of  the  regular  ar- 
ranged longitudinal  canals,  the  new  osseous  deposition  presents 
irregular  cavities,  varying  in  size  and  direction.*  This,  together 
with  great  vascularity,  constitutes  the  anatomical  character  of  such 
deposits.  In  one  skull  under  7 in  my  collection,  periosteal  in- 
flammation has  produced  on  the  parietal  bone  a circular  area  the 
size  of  a shilling,  of  minute  spherical  or  spheroidal  eminences,  sur- 
rounded by  a smooth  whitish  ring,  and  that  enclosed  by  a darker 
coloured  ring.  The  circular  area,  with  rough  eminences,  marks 
the  space  from  which  the  periosteum  was  detached.  It  is  thicker 
and  less  translucent  than  the  rest  of  the  bone.  The  white  ring 
indicates  the  tract  where  the  pericranium  was  inflamed,  but  not 
detached. 

7.  If  the  inflammation  be  acute,  as  in  that  from  injury,  it  may] 
produce  ulcerative  absorption  of  the  subjacent  bone,  which  then 
presents  a denuded,  rough,  reddish  surface,  progressively  increasing  Jf 
in  extent  and  depth.  This  occurs  particularly  in  young  subjects.  ^ 
I have  seen  it  in  the  bones  of  the  skull  destroy  both  tables,  and 
expose  the  dura  mater ; and  the  fact  shows  that  the  tendency  to 
suppurative  inflammation  in  the  bones  of  the  young  is  great.  Of  this 
the  following  case  is  a good  example. 

A young  girl  of  10  or  11  years  of  age  received  on  the  head 
a blow  from  a stone,  which  divided  the  scalp  down  to  the 
bone,  but  without  causing  fracture  or  depression.  The  wound 

* Chirurgical  Observations  and  Cases.  By  William  Bromfield,  Surgeon  to  Her 
Majesty  and  to  St  George’s  Hospital.  Vol.  II.  Chap.  i.  p.  14.  London,  1772. 

T Howship  in  Medico-Chirurg.  Trans.  Vol.  VIII.  pp.  90,  and  105,  106. 


BONE. 


449 


bled  freely  and  was  dressed  in  the  ordinary  way.  A few  days  after 
the  parents  requested  the  advice  of  an  able  surgeon,  who,  finding 
the  wound  swelled,  hot,  and  painful,  with  scanty  discharge,  recom- 
mended the  application  of  an  emollient  poultice,  and  the  use  of  low 
diet  with  laxative  medicine.  In  the  course  of  a few  days,  suppura- 
tion took  place  to  a great  extent,  yet  without  any  appearance  of 
the  wound  healing  or  adhering.  The  patient  also  complained  of 
pain  in  the  head,  especially  girding  frontal  headach ; the  appetite 
was  gone;  the  pulse  was  quick,  above  120;  she  looked  pale  and 
unwell ; and  occasionally  felt  shivering  sensations. 

At  this  stage,  about  15  or  16  days  after  the  infliction  of  the 
wound,  the  surgeon  requested  me  to  see  the  child.  The  following 
was  the  state  of  matters.  The  lips  of  the  wound  were  red,  large, 
and  gaping;  much  matter  was  proceeding  from  it;  and  it  was 
the  seat  of  very  distinct  pulsation,  synchronous  with  that  of  the  arte- 
ries; while,  when  the  child  cried,  or  breathed  strongly,  or  coughed, 
matter  issued  copiously  from  the  wound.  When  this  matter  was  re- 
moved by  the  use  of  dry  charpee,  it  w'as  then  distinctly  seen  that  an 
aperture  had  been  completely  formed  through  the  bone  into  the 
dura  mater ; that  the  brain  and  its  membranes  were  exposed  at 
the  bottom  of  the  wound,  showing  the  two  motions  of  the  brain. 
The  wound  was  in  the  right  parietal  bone  near  the  coronal  suture. 

The  question  was,  what  w'as  to  be  done  ? I recommended  that 
a little  blood  should  he  drawn  from  the  arm ; that  the  poultices 
should  be  given  up ; that  the  wound  should  he  kept  clean  and  cool 
by  occasional  ablution  with  cold  water ; that  a light  dressing  con- 
sisting of  lint  dipped  in  cold  vrater,  or  a solution  of  sulphate  of 
zinc,  should  be  applied  over  the  surface  of  the  wound  ; and  that  the 
patient  should  be  kept  quiet,  and  on  moderate  unstimulating  diet. 

This  plan  was  immediately  adopted.  In  a few  days  the  headach 
had  subsided,  the  discharge  was  greatly  diminished,  the  pulsating 
and  heaving  motion  of  the  wound  w'as  no  longer  observed ; new 
bony  matter  was  deposited,  and  closed  the  aperture  in  the  parietal 
bone  ; and  in  about  10  days  more  the  wound  was  entirely  healed. 

In  this  case,  as  there  was  ulceration  of  bone  and  loss  of  its  sub- 
stance, there  must  have  been  deposition  and  new  formation  of  it. 
The  process  I regard  as  peculiar  to  the  young. 

It  takes  place  also  in  the  tibia,  in  the  sternum,  and  other  super- 
ficial bones.  In  a more  chronic  form  I have  seen  it  cut  through 
both  nasal  bones  by  insensible  ulcerative  absorption.  This  process 
corresponds  with  the  insensible  ex  foliation  or  decomposition  of  Tenon  ; 


450 


GENERAL  AND  PATHOLOGICAL  ANAT05IY. 


the  ahsorption  produced  by  tumours,  aneurisms,  and  other  compres- 
sing agents ; (Louis,  Wilmer ;)  and  the  peculiar  absorption  described 
by  Mr  Russell.* 

A similar  process,  by  causing  suppurative  destruction  or  even 
death  of  the  periosteum,  may  kill  the  subjacent  bone  (nekrosis,) 
which  then  becomes  white,  yellow,  or  black,  and  presents  a de- 
nuded but  uniform  surface,  bounded  at  certain  points  by  an  irre- 
gular  rough  line;  (crena.)  This  line,  which  denotes  the  establish- 
ment of  ulceration  on  the  confines  of  the  living  bone,  becomes 
more  complete  and  deeper,  till  the  dead  portion  is  loosened  and 
removed.  This  process  is  denominated  exfoliation^  and  the  part  so 
removed  is  said  to  be  exfoliated f By  Weidmann,  who  justly  re- 
marks that  these  terms  are  too  limited,  the  process  is  designated  by 
the  general  name  of  separation  ; while  the  part  separated  is  distin- 
guished by  the  epithet  ramentum.  Though  it  takes  place  chiefly 
in  the  bones  of  tbe  skull  and  in  the  front  of  the  tibia,  it  may  occur 
in  the  low'er  jaw,J  in  those  of  the  pelvis,§  in  the  femur,  and 
wherever  the  structure  is  close  and  compact.  In  this  manner  the 
odontoid  process  of  the  epistrophe  {vertebra  dentata)  has  been  known 
to  be  removed.  II  In  bones  containing  much  cancellated  structure, 
for  instance  the  vertebrae,  sternum,  the  carpal  and  tarsal  bones,  this 
suppurative  destruction  and  death  of  the  periosteum  produces  not 
death  and  exfoliation,  but  caries  or  ulceration,  with  death 

of  minute  particles  of  bone,  {separatio  insensibilis.) 

£.  Certain  forms  of  periosteal  inflammation  give  rise  simulta- 
neously to  osseous  deposition  and  ulceration  or  caries.  Thus  no- 
dose inflammation  of  the  tibia  and  fibula  may  terminate  in  ulcers 
of  the  periosteum,  and  produce  irregular  deposition  on  the  surface 
of  these  bones,  which  appear  thick,  but  without  the  usual  aspect  of 
healthy  bone,  present  irregularly  shaped  masses  of  structure,  partly 
like  honey-comb  cells  and  partitions,  partly  like  confused  network. 
The  course  of  phenomena  here  is  first  chronic  thickening  and  in-, 
duration  of  the  periosteum,  with  deposition  of  bone  beneath  it; 


* Edinlmrgh  Medico-Chirurgical  Transactions,  Vol.  I.  p.  74. 

T Memoires  sur  I’Exfoliation  des  Os,  par  M.  Tenon,  dans  Mem.  de  I’Academie  R. 
des  Sciences,  1758.  P.  661,  &c.,  and  1760.  See,  among  others,  good  cases  in  How- 
ship's  Practical  Observations,  Case  107,  pp.  404,  and  113,  p.  434. 

:J;  Exfoliations  of  the  lower  jaw  from  disease  or  injury  of  the  alveolar  processes  are 
common.  The  hasty  and  reckless  use  of  the  tooth-key  I have  known  produce  not  a 
few  examples  of  exfoliation  of  both  jaw-bones. 

§ In  Mr  J.  Bell's  case  of  Gluteal  Aneurism  exfoliation  from  the  ilium  and  sacrum 
took  irlace.  Principles,  Vol.  I.  p.  423. 

11  Mr  James  Syme’s  Case  in  Med.  and  Surg.  Journal,  Vol.  XXV.  p.  311. 


BONE. 


451 


then  ulceration  of  the  periosteum ; and  lastly,  ulceration  or  caries 
in  the  new  bony  matter,  which  appears  to  continue  to  he  deposited 
irregularly.  This,  which  is  the  carious  ulcer  (ulcus  cariosum,')  of 
practical  authors,  may  be  seen  in  the  legs  of  those  who  have  been 
affected  by  the  constitutional  symptoms  of  syphilis,  and  who  have 
undergone  for  its  cure  repeated  courses  of  mercury.* * * §  In  the  cases 
in  which  I have  seen  it,  it  gave  rise  to  extreme  local  pain  and  great 
constitutional  disorder,  requiring  amputation ; and  one  case  ter- 
minated fatally.  Occurring  in  the  bones  of  the  cranium,  which  it 
occasionally  does,  it  is  one  of  the  forms  of  the  disease  described  by 
the  older  authors  under  the  fantastic  appellation  of  the  garland  of 
Venus ;( CbroHo  Veneris.) 

Exostosis  Periostei.  Osteosarcoma.  That  the  periosteum 
may  be  concerned  in  extensive  but  morbid  secretion  of  osseous 
matter,  giving  rise  to  that  form  of  tumonr  which  has  been  term- 
ed by  some  exostosis,  and  by  others  osteosarcoma,  has  been  al- 
ready noticed.  (P.  424.)  The  periosteum  becoming  thicken- 
ed and  morbidly  vascular  and  painful,  assumes  additional  energy 
in  the  deposition  of  bony  matter  over  a certain  space.  But 
the  bone  so  deposited  is  never  arranged  in  the  manner  of  heal- 
thy bone.  Sometimes  it  is  in  the  form  of  a large  shapeless  pro- 
minence deposited  on  the  outer  surface  of  the  original  bone. 
This,  which  was  remarked  by  Pouteau,f  Houstet,!  Herissant,§ 
Flajani,!  and  Monteggia,  has  been  verified  by  Howship.  Some- 
times it  occurs  in  one  point  of  the  bone  in  the  form  of  a spheroidal 
tumour,  in  which  the  osseous  matter  is  arranged  in  the  form  of 
long  needle-like  fibres,  radiating  from  one  or  more  points,  not  un- 
like radiated  zeolite.  In  other  instances  it  occurs  in  the  form  of 
amorphous  masses  of  bone,  much  like  pieces  of  calcareous  sinter. 
(Houstet.)  In  others  again,  a central  granular  mass  is  surrounded 
by  acicnlar  bony  fibres. 

Of  these  growths  the  interior  structure  varies.  They  are  never 
masses  of  solid  bone ; but  the  bony  matter  is  so  arranged  that  it 
leaves  spaces  or  intervals  filled  in  some  instances  with  soft  flesh- 
coloured  spongy  matter ; (the  fungous  exostosis  of  Sir  A.  Cooper  ;) 

* Of  this  kind  appear  to  be  the  tibia  and  fibula  delineated  by  Roberg.  See  his 
Dissert,  in  Haller  Disp.  Chimrg.  Tom.  IV.  p.  561. 

t CEu-STes  Posthumes,  Tom.  III. 

+ Mem.  de  I’Acad.  de  Chir.  Tom.  III.  p.  130. 

§ Mem.  de  I’Acad.  Roy.  des  Sciences.  1758,  p.  676. 

II  Collezione  d'Osservaz.  e Rifless.  Tom.  II. 


452 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


in  others  with  cartilage;  (J.  Bell,  A.  Cooper,)  (the  cartilaginous 
exostosis ;)  in  others  with  colloid  or  jelly-like  matter,  (J.  Bell ;) 
in  others  with  semifluid  blood-like  matter,  (Houstet ;)  and  in  some 
instances  they  have  been  known  to  contain  hydatids,  (Keate,  &c.) 
In  all  cases  the  periosteum  is  thickened ; the  tumour  is  penetrated 
by  numerous  large  vessels ; and  the  bone  in  which  the  exostosis  is 
formed  is  more  or  less  thinned  and  destroyed  by  absorption. 
(Houstet,  J.  Bell,  Palletta,*  Sir  A.  Cooper.) 

Though  periosteal  exostosis  may  take  place  in  any  bone  of  the 
skeleton,  it  most  frequently  appears  on  the  inner  side  of  the  thigh- 
bone above  the  internal  condyle,  or  upon  the  shaft,  which  it  may 
enclose  completely,  (Houstet ;)  next  upon  the  tibia,  which,  with 
the  fibula,  it  may  encompass  more  or  less  perfectly  ; next  upon  the 
humerus,  (J.  Bell  and  Cooper ;)  next  in  the  bones  of  the  pelvis, 
(Cheston  and  Sandifort ;)  and  finally,  on  such  bones  as  the  lower 
jaw,  the  temporal,  and  other  bones  of  the  cranium.  It  is  most 
likely  to  take  place  at  muscular  or  tendinous  insertions-f 

In  these  forms  of  osseous  deposition  the  vitality  of  the  new  deposit 
is  small.  Its  organization  is  indistinct  and  imperfect;  and  in  no 
long  time  it  proceeds,  apparently  by  pressure,  to  destroy  the  struc- 
ture of  the  adjoining  bone,  which  then  becomes  rough,  yellowish, 
or  even  black,  and  undergoes  absorption.  The  bony  mass  at  the 
same  time  is  changed  interiorly,  presenting  cavities  containing  ge- 
latinous or  sanious  fluid.  The  adjoining  soft  parts  are  generally 
destroyed  by  pressure ; and  when  they  give  way  are  wasted  by  bad, 
but  not  cancerous  ulceration.  The  bone  thus  exposed  is  generally 
black,  rough,  and  carious.  Though  no  exact  analysis  of  these  os- 
seous tumours  has  yet  been  made,  it  is  known  that  they  consist  of 
phosphate  of  lime  with  animal  matter. 

The  bony  tumours  occurring  in  the  carpal,  metacarpal,  and  pha- 
langeal bones,  as  described  by  Severinus,  Mery,  and  Mr  John  Bell, 
I am  inclined  to  refer  to  the  head  of  exostosis  depending  on  disease 
of  the  medullary  membrane. 

b.  The  medullary  filamentous  web  is  perhaps  still  more  impor- 
tant than  the  periosteum  in  its  morbid  influence  on  bone.  It  is,  in 
the  first  place,  liable  to  inflammation ; and,  according  as  this  takes 
place  in  the  medullary  web  of  the  cylindrical  bones,  or  in  that  of 
their  epiphyses,  or  of  the  short  irregular  bones,  different  effects  re- 
sult. 

* Exercitationes  Pathologic*,  Cap.  ix.  Art.  iii.  p.  112-115. 

f On  Exostosis,  by  Sir  A.  Cooper  in  Surgical  Essays,  Part  i.  London,  1818,  p.  155. 


BONE. 


453 


Cl.  Nekrosis.  The  term  nekrosis  means  the  process  or  state  of 
dying  or  mortification  in  general  ; but  it  is  restricted  by  pa- 
thologists and  surgeons  to  designate  death  taking  place  in 
bone.  This  may  be  accomplished  in  various  ways,  and  may 
be  the  result  of  the  operation  of  various  agents.  A compound 
comminuted  fractui’e,  a gun-shot  which  breaks  and  shatters  a bone, 
or  any  other  considerable  degree  of  violence,  may  be  followed 
by  death  of  the  portions  most  directly  injured,  and  even  those 
less  immediately  injured.  It  is  observed  also  in  the  course  of  dis- 
eases and  accidents  that  when  any  one  of  the  compact  bones  is  de- 
nuded of  its  periosteum,  the  part  so  denuded  is  very  liable  to  be- 
come dead  and  to  be  then  separated  as  a lifeless  part.  In  some 
instances  it  has  been  observed  that  the  agency  of  fire  applied  to  the 
human  body  accidentally  or  intentionally  has  caused,  by  denuding 
the  bone,  the  same  result.  Thus  the  actual  cautery  applied  to  the 
scalp  has  caused  death  of  the  external  table ; and  I have  seen  a 
portion  of  the  same  external  table  destroyed,  and  made  to  exfoliate 
in  an  epileptic  patient  who  in  one  of  his  fits  had  fallen  into  the 
fire. 

A peculiar  sort  of  nekrosis  of  the  bones  of  the  face,  especially 
the  superior  jaw,  has  been  made  known  by  one  of  the  manufactures 
of  modern  times.  It  is  observed,  that  persons  engaged  in  lucifer- 
match  manufactories  are  liable  to  be  attacked  with  pain  and  swelling 
of  the  face ; and  eventually  it  is  observed,  that  the  soft  parts  about 
the  nostrils  suppurate,  and  portions  of  dead  bone  are  discharged 
evidently  from  the  upper  jaw.  The  process  is  chronic,  tedious,  and 
exhausting;  and  sometimes  the  face  is  greatly  deformed.  This 
disease  is  ascribed  to  the  agency  of  phosphorus  in  vapour,  which 
is  believed  in  this  manner  to  produce  death  of  the  bones  of  the  up- 
per jaw. 

All  these  are  modes  in  which  nekrosis  or  death  of  bone  may  be 
produced. 

The  terra  is  nevertheless  most  commonly  applied  to  designate 
death  in  any  of  the  cylindrical  bones,  in  which  the  disease  is  seen 
in  its  greatest  perfection ; and,  as  it  is  sometimes  under  certain  cir- 
cumstances attended  with  attempts  to  form  new  bone  to  supply  the 
place  of  the  dead  bone,  the  term  has  been  often  understood  to  em- 
brace the  latter  process  as  well  as  the  former.  The  formation  of 
new  bone,  nevertheless,  does  not  take  place  always  ; and  that  must 
be  regarded  as  a distinct  part  of  the  process. 

Nekrosis  may  come  on  in  different  modes.  Often  it  is  sponta- 


454 


GENERAL  AND  rATHOLOGICAL  ANATOMY. 


neous  in  origin,  and  its  appearance  cannot  be  traced  to  any  exter- 
nal cause.  In  other  cases  it  is  observed  to  appear  some  time  after 
a blow,  or  other  injury,  in  which  the  bone  has  suffered  considerable 
concussion. 

The  disease  may  make  its  appearance  in  two  forms ; either  as  a 
chronic  malady,  which  is  most  usual  ; or  as  one  of  great  acuteness, 
with  intense  symptoms  of  general  and  local  disorder. 

When  it  approaches  as  a chronic  disease,  the  individual  has  pains 
in  the  leg,  or  thigh,  or  arm  of  the  part  to  be  affected,  which  is  re- 
ferred to  the  bone ; the  pain  is  aggravated  by  walking  and  all  mo- 
tion ; and  there  is  in  the  limb  a sense  of  weight  with  weakness, 
which  makes  the  patient  afraid  lest  anything  is  to  injure  it.  After 
some  time  swelling  takes  place  all  over  the  limb.  Occasionally 
attacks  come  on  like  rose  affecting  the  limb ; and  either  soon  or 
after  several  of  these  attacks  matter  is  formed ; and  upon  being 
discharged  spontaneously  or  by  art,  the  bone  is  found  bare,  in  more 
or  less  extent,  and  sometimes  rough  and  parts  of  it  loose. 

In  another  class  of  cases  the  patient  suffers  deep-seated  gnawing- 
pain,  referred  to  one  part  of  the  bone,  which  is  aggravated  and 
extended  over  the  whole  bone  on  attempting  to  walk  or  otherwise 
persisting  in  using  the  limb.  The  patient  is  also  lame  and  in  ge- 
neral little  able  to  walk.  The  limb  is  swelled ; over  the  bone  much 
thickening  and  swelling  are  felt ; generally  pain  on  pressure  is  felt ; 
and  the  surface  is  unusually  hot.  At  length,  from  some  very  slight 
and  inadequate  cause,  as  endeavouring  to  stand  on  the  limb,  or  in 
the  course  of  walking,  if  that  has  not  been  abandoned,  the  patient 
is  seized  with  sudden  and  immediate  loss  of  power  in  the  limb,  and 
he  falls  down  helpless  and  motionless.  When  the  bone  is  examin- 
ed, it  is  found  that  fracture  has  taken  place. 

In  some  rare  cases  this  fracture  unites  after  a considerable  time 
in  the  usual  way,  with  much  effusion  of  callus  and  deposition  of 
bone.  In  a much  larger  proportion  of  cases  suppuration  takes 
place ; matter  finds  its  way  to  the  surface  ; and  when  by  an  opening 
by  art  or  spontaneously,  it  is  allowed  to  escape,  the  bone  is  found 
to  be  extensively  stripped  of  periosteum,  to  be  rough  and  irregular, 
and  without  any  attempts  at  union.  This  suppurative  process  ad- 
vances, enfeebling  the  patient,  who  pines  away  in  hectic  fever,  and 
in  no  long  time  dies. 

The  state  of  the  bone  is  then  remarkable.  No  attempt  at  union 
is  observed ; the  broken  ends  of  the  bone  are  white,  rough,  and 

lifeless,  and  for  a considerable  space  deprived  of  periosteum.  The 

l 


BONE. 


455 


medullary  caual  contains  purulent  matter ; on  the  removal  of  which 
the  cancelli  are  observed  also  to  be  white  and  rough,  while  a little 
farther  away  from  the  fragments  the  medullary  web  is  vascular, 
swelled,  and  discharging  purulent  matter.  In  general,  beyond  the 
white  portion  of  bone,  a rough  depressed  line  is  observed  between 
the  living  and  dead  parts,  the  former  having  In  general  the  peri- 
osteum attached,  and  which  is  thickened,  vascular,  and  evidently 
in  a state  of  inflammation. 

The  acute  form  of  the  disease  is  greatly  more  violent  in  pheno- 
mena and  more  rapid  in  progress.  All  at  once  a limb  or  a por- 
tion of  it,  for  instance  the  leg  or  thigh,  is  attacked  with  general 
swelling,  diffused  over  the  whole  limb,  great  and  intense  pain  both 
superficial  and  deep,  while  the  surface  is  hot  and  tense,  of  a dull 
red  colour,  or  sometimes  very  faintly  red ; and  the  patient,  be- 
sides a feeling  of  great  weight  in  the  limb,  is  entirely  deprived  of 
all  powers  of  moving  it.  The  constitutional  disorder  is  great. 
Generally  there  are  rigors  succeeded  by  heats ; the  pulse  is  quick, 
full,  and  strong ; pain  is  felt  in  the  head ; the  tongue  is  furred  and 
dry ; the  patient  distressed  with  thirst,  restlessness,  and  anxiety, 
and  is  in  certain  cases  delirious ; the  complexion  is  brownish-red 
as  in  phlebitis j the  eyes  are  glaring  ; and  the  expression  is  a mijt- 
ture  of  wildness  and  great  suffering.  This  general  disorder  is  in 
certain  cases  so  intense,  and  causes  so  great  a shock  to  the  system, 
that  the  patient  expires  in  the  course  of  three  or  four  days ; and 
before  the  local  disorder  has  lasted  sufficiently  long  to  produce 
suppuration. 

If  the  patient,  however,  survive  this  period,  the  swelling  invari- 
ably proceeds,  until  suppuration  takes  place  in  one  or  more  parts. 
In  the  course  of  one  or  two  days  more,  matter  points  in  one,  two, 
or  three  places  simultaneously  or  successively ; and  when  this  is 
allowed  to  find  issue  either  by  art  or  spontaneously,  it  is  ascertained 
that  inflammation  has  existed  over  the  whole  bone  and  the  soft  co- 
verings, and  that  this  has  proceeded  most  extensively  to  suppura 
tion.  The  skin  and  adipose  membrane  are  by  this  detached  from 
ihefascice;  the  fasciae  are  detached  from  the  muscles;  the  muscles 
from  each  other ; and  the  whole  soft  parts  are  more  or  less  detach- 
ed from  the  periosteum,  which,  again,  is  either  shreddy  and  killed, 
or  is  detached  in  parts  from  the  subjacent  bone,  which  is  in  these 
points  rough,  white,  and  evidently  either  deprived  of  vitality  or 
very  much  injuj-ed  in  texture.  When  the  bone  is  cut  open  longi- 


456 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


tudiiially,  the  medullary  membrane  is  swelled  and  very  vascular, 
loaded  with  blood  and  serum,  and  presenting  in  various  points  drops 
of  purulent  matter. 

The  veins  of  the  limb  are  inflamed  ; and  their  coats  are  thicken- 
ed and  sometimes  obliterated.  The  arteries  are  denuded,  brittle, 
and  present  traces  of  having  partaken  in  the  general  inflammatory 
orgasm. 

This  form  of  nekrosis  appears  very  similar  to  an  attack  of  diffuse 
inflammation  of  the  adipose  and  filamentous  tissue;  and  I have 
occasionally  entertained  doubts  whether  it  ought  not  to  be  regarded 
as  such  primarily,  or  as  general  inflammation  of  the  soft  parts  af- 
fecting eventually  and  necessarily  the  bone.  It  also  presents  some 
resemblance  to  inflammation  of  the  blood-vessels,  and  especially  of 
the  veins.  The  point  is  practically  of  little  moment.  The  bone  is 
killed ; whether  primarily  or  secondarily  appears  of  little  conse- 
quence, unless  we  could  thereby  discover  some  means  by  which 
an  action  so  destructive  might  be  stayed  in  its  progress. 

An  important  question  presents  itself:  to  determine  what  is  the 
anatomico-pathological  cause  of  nekrosis  ; which  is  the  texture  con- 
cerned in  its  production  ; whether  it  be  always  one  and  the  same 
texture,  or  whether,  in  different  cases  and  different  forms  of  the 
disease,  different  textures  are  concerned.  This  question  it  seems 
difficult  to  determine.  All  that  is  already  known  tends  to  show 
that  nekrosis  may  be  the  effect  of  previous  disease  of  the  perioste- 
um, previous  disease  in  the  medullary  membrane  or  in  both,  or  of 
the  whole  of  the  soft  parts  investing  the  bone.  The  rest  may  be 
understood  from  what  follows. 

Nekrosis  interna. — That  the  medullary  web  of  the  cylindrical 
bones  is  liable  to  inflammation  is  a well  established  point.  The  ten- 
dency of  this  is  not  so  well  understood.  It  may  proceed  either  to 
suppuration,  forming  a collection  of  matter  within  the  cavity  of  the 
bone;  or  by  producing  effusion  within  the  interstices  of  the  medullary 
web  it  may,  by  causing  induration  and  swelling,  induce  expansion 
of  the  walls  of  the  diaphysis ; or  by  destroying  the  medullary  mem- 
brane, it  may  kill  the  bone  from  within  outwards. 

That  inflammation  of  the  medullary  web  causes  swelling  and  ef- 
fusion into  its  interstices  may  be  regarded  as  established  by  the 
phenomena  of  fractures,  simple  and  compound,  and  especially  by 
those  experiments  in  which  this  texture  is  expressly  injured.  When 

it  proceeds  without  being  resolved,  it  may  cause  a uniform  expan- 

3 


BONE. 


457 


sion  of  the  bone,  which  very  often  precedes  the  extinction  of  its  vi- 
tality. 

Thus  in  most  of  the  instances  of  the  incipient  stage  of  nekrosis, 
a local  enlargement,  or  rather  dilatation  of  the  bone,  takes  place, 
while  the  bone,  though  its  texture  is  softened,  is  still  alive.  This 
is  the  process  which  Scai’pa  distinguishes  under  the  name  of  expan- 
sion, and  in  which  he  imagines  the  reticular  structure  to  be  relax- 
ed or  unfolded.  The  fact  is  well  established,  but  the  explanation 
is  gratuitous.  It  is  doubtless  the  early  stage  of  the  process  which 
terminates  in  nekrosis. 

Suppuration  in  the  cavity  of  the  long  bones,  which  was  seen  by 
Cheselden,  (p.  40),  Gooch,  (Vol.  II.  p.  357,)  Hey,  (p.  26  and  32,) 
and  others,  is  generally  a process  so  severe  as  to  cause  death  by 
constitutional  irritation.  If  it  fails  to  effect  this,  it  first  distends 
and  softens  the  bone,  and  then  kills  it  from  within  outwards,  in- 
ducing nekrosis.  This  may  affect  either  part  or  the  whole  of  the 
diaphysis,  which  is  then  separated  from  the  periosteum  and  epiphy- 
sis, which  is  rarely  killed.  In  process  of  time  the  dead  portion  or 
portions  (^ramenta,)  become  enclosed  more  or  less  completely  by  a 
thick  shapeless  cylinder  of  new  bone,  with  or  without  openings  in 
its  sides,  and  which  is  placed  between  the  epiphyses  and  covered 
by  the  periosteum,  which  is  much  thickened.  If  death  take  place 
at  this  period,  the  bone  thus  formed  is  found  to  contain  the  origi- 
nal shaft,  loose  and  dead.  If  life  be  still  prolonged,  the  old  bone 
generally  piecemeal  is  gradually  brought  to  the  surface  through 
the  openings  in  the  new  osseous  case  and  expelled.  The  fragments 
thus  discharged,  which  are  of  a dirty,  yellow,  drab,  or  black  colour, 
and  somewhat  corroded  or  worm-eaten  at  the  ends  and  margins, 
are  named  sequestra  by  Troja,*  David,f  and  other  French  surgeons ; 
and  ramenta  by  Weidmann.  The  channels  or  openings  through 
which  they  are  expelled,  which  are  temporary  deficiencies  in  the 
new  bone,  are  termed  cloacce.X 

The  above  is  a brief  description  of  the  process  of  nekrosis  with 
regeneration,  as  it  occurs  in  the  cylindrical  bones.  Its  effects  were 
known  long  before  its  mechanism  was  understood.  The  fact  of 
portions  of  the  cylindrical  bones  of  the  extremities  being  removed 
or  expelled  without  impairing  the  motion  of  the  limb,  and  of  one 

* De  Novorum  ossium  regeneratione  exp.  Paris,  1775. 

t Observations  sui  une  Maladie  connue  sous  le  nom  de  Necrose.  Paris,  1782. 

J J.  Petr.  Weidmann,  M.  D.,  &c.  De  Necrosi  Ossium.  Francofurti  ad  Mcenum. 
1793.  Fobo. 


458 


GENERAL  AND  PATHOLOGICAL  ANATOMY, 


bone  being  found  within  another  was  remarked  Duverney,  Ruysch,* 
a Meek’ren,!  Cheselden  and  others  of  the  older  anatomists  and  sur- 
geons ; and  even  Portal  speaks  of  the  circumstance  of  one  bone 
rattling  within  another  as  a curious  and  unexplained  phenomenon.^ 
Next  to  the  case  given  by  Cheselden,  Laing§  in  1737,  and  John- 
ston||  in  1742,  described  cases  of  removal  of  the  tibia  and  regene- 
ration of  the  bone.  Trioen^  and  Amyand**  describe  the  same  ^ 
facts  under  the  name  and  as  examples  of  spina  ventosa  ; and  Mac-j  ■ 
kenzie,tt  William  Hunter,JJ  Ludwig,§§  Bromfield,||||  and  others  de-  ' 
scribe  the  disease  with  the  process  of  regeneration  under  various 
names,  as  detachment  of  the  epiphyses^  caries,  loss  of  a bone,  or  re- 
production, destruction  of  the  diaphyses,  according  as  any  one  part 
of  the  process  was  most  prominent,  without  appearing  to  be  aware 
of  its  true  nature.  Ludwig,  indeed,  appears  to  have  been  the  first, 
or  among  the  first,  who  investigated  carefully  the  nature  of  the 
change.  He  published  in  1772  two  cases  of  the  disease  ; one  in  the! 
tibia,  with  recovery ; and  another  in  the  femur,  in  which  the  pa-|| 
tient  had  died,  and  in  which  he  described  the  appearances  found  in  ' 
the  bone.  In  the  latter  case  a considerable  dead  fragment  of  the . ; 
os  femoris  had  come  away  in  the  fifteenth  year  of  the  patient,  six  years 
after  the  commencement  of  the  disease,  followed  by  about  30  frag- 
ments varying  in  size.  This  patient  survived  to  her  25th  year ; 

• Thesaur.  Anatom.  VIII.  Fig.  2,  3,  4. 

f Jobi  a Meek’ren  Chirurgi  Amsteloclamensis  Observationes  Medico-Chii'urgicae. 
Amstelodami,  1682.  Cap.  LXIX.  p.  328.  Part  of  the  humervjS. 

$ Anatomic  Medicate,  Tome  I.  p.  32. 

§ The  larger  space  of  the  Tibia  taken  out,  and  afterwards  supplied  by  Callus.  By 
Mr  David  Laing,  Surgeon  at  Jedburgh.  Edin.  Med.  Essays,  VoL  I.  Art.  XXIII.  p. 

238.  Edin.  1737. 

II  A History  of  the  Tibia  taken  out  and  regenerated.  By  Mr  William  Johnston,^ 
Surgeon  in  Dumfries.  Ed.  Med.  Essays  and  Obs.  Vol.  V.  Art.  XL.  p.  452.  Edin.  1742. 

Cornelii  Trioen,  Med.  Doc.  Observationum  Medico-Chirurgicorum  Fasciculus.  *. 
Lugduni  Batav.  1743,  4to.  p.  105. 

**  Some  Observations  on  the  Spina  Ventosa.  By  the  late  Claudius  Amyand,  Esq., 

F.  R.  S.,  &c.  Phil.  Transactions,  Vol.  XLIV.  Part  I.  for  1746.  London,  1748, p.  193. 

ft  A Remarkable  Separation  of  part  of  the  Thigh  Bone.  By  Dr  Mackenzie,  read 
14th  July  1760.  Med.  Observations  and  Inquiries,  Vol.  II.  London,  1762,  p.  299. 

An  Account  of  a Diseased  Tibia,  as  a Supplement  to  the  last  article.  By  William  ^ . 
Hunter,  M.  D.  Ibid.  p.  303.  | 

§§  Tractatio  de  Diaphysibus  ossium  cylindricorum  laesis  exfoliatione  separatis  et  callo 
subnato  restitutis.  Ludwig  Adversaria  Medico  Practica,  Vol.  III.  Part  I.  Lipslae, 
1772,  p.  45,  Art.  II. 

III!  Chirurgical  Observations  and  Cases.  By  William  Biomfield,  Surgeon  to  her  Ma- 
jesty and  to  St  George’s  Hospital,  Vol.  II.  p.  18,  and  Plate  I.  This  represents  what  is 
called,  “ a very  remarkable  carious  bone  from  the  Museum  of  Dr  Frank  Nicholls,”  p. 

342.  It  is  a nekrosed  os  Aamcri.  London,  1773. 


BONE. 


459 


and  after  death  the  shaft  or  diaphysis  of  the  os  femoris  was  found 
very  thick,  rough,  irregular,  and  with  a large  hole  and  cavity  pass- 
ing into  the  interior  of  the  hone.  He  is  the  first  author  who  speaks 
of  reproduction  of  the  hone. 

Louis  appears  to  have  first  applied  the  epithet  nekrosis  ; hut  Cho- 
part  and  David  were  the  first  who  directed  the  attention  of  surgeons 
to  the  process  of  regeneration  ; and  about  the  same  time  Troja  and 
David,  and  afterwards  Blumenhach,  Koeler,  Macdonald,  and  De- 
sault, investigated  the  manner  in  which  this  is  eftected. 

hleanwhile  Andrew  Bonn,  who  published  in  1785  an  account 
of  the  diseased  bones  contained  in  the  museum  of  Hovius,  gave 
six  examples  of  the  disease,  sometimes  without,  sometimes  with 
attempts  at  reproduction  of  bone.  In  the  cases  in  which  repro- 
duction took  place,  the  usual  phenomena  of  great  and  extensive 
deposition  of  bone  round  the  site  of  the  old  bone,  with  much  irre- 
gularity of  figure  and  thickness,  perforations  in  the  remains  of 
them,  on  the  body  of  the  new  osseous  matter,  and  fragments  of 
mortified  bone,  ulcerated,  and  showing  traces  of  having  been  subjected 
to  maceration  in  purulent  matter.  His  general  conclusion  deserves 
attention.  “By  these  various  instances,”  saysBonn,  ‘‘from Plate XV. 
to  Plate  XXHI.  it  is  proved,  that  by  a uniform  law  of  nature,  a bone 
diseased  and  mortified  is  separated  from  the  living  bone,  by  a notch, 
[cre«a,]  or  ulcerated  depression,  and  by  the  successive  growth  of 
membranous  matter  which  is  eventually  converted  into  bone.”* 

Two  circumstances  in  the  history  of  nekrosis  merit  attention  ; 
Jirst,  the  cause  of  the  death  of  the  bone ; and,  second,  the  agent  of 
its  reproduction.  I have  already  stated  inflammation  of  the  me- 
dullary web  to  be  the  cause  of  the  former ; and  this  I conceive  to 
be  proved  not  only  by  the  phenomena  of  the  disease,  hut  more 
directly  by  the  experiments  of  Troja,  David,  and  Macdonald,  who 
have  performed  experiments  of  the  same  description.  From  these 
experiments  it  may  be  inferred,  that  suppurative  destruction  or 
death  of  the  medullary  web  is  necessarily  followed  by  death  of  the 
surrounding  bone. 

The  same  experiments,  with  the  relative  situation  of  the  new  bone, 
unequivocally  prove  that  the  periosteum  and  its  vessels  are  the  agents 
of  reproduction.  Whether  by  accident  or  spontaneously  the  medul- 
lary web  is  destroyed,  if  the  periosteum  be  uninjured,  it  becomes 
thick,  swollen,  and  highly  vascular  ; bony  matter  in  the  fluid  form 

* Andre®  Bonn  Descriptio  Thesauri  Ossium  Morbosorum  Hoviani.  Lipsiae,  1784. 
Tabulae,  1785,  1789. 


460 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


is  then  deposited  with  more  or  less  regularity  from  its  interior  sur- 
face ; and  after  this  has  acquired  a due  degree  of  thickness,  the 
vascularity  and  swelling  of  the  periosteum  gradually  diminish,  till 
the  membrane  is  restored  to  its  natural  state.  When,  on  the  con- 
trary, the  periosteum  is  injured  or  destroyed,  regeneration  is  im- 
perfect or  altogether  deficient.  (M^eidmann.)  In  some  instances 
also,  in  which  necrosis  affects  one  portion  only  of  the  internal  sur- 
face of  a cylindrical  bone,  reproduction  appears  not  to  be  effected. 
The  outer  part  of  the  bone  then  becomes  soft,  and  at  length 
carious,  and  forms  apertures  {foramina  grandia,  Troja),  {cloaca, 
Weidmann,)  similar  to  those  in  new  osseous  cases,  through  which  a 
sequestrum  is  discharged.  (Weidmann,  p,  31.) 

In  short,  the  doctrine  of  those  who  have  maintained  that  the 
periosteum  is  the  chief  agent  of  reproduction,  is  that  the  old  bone, 
or  that  which  was  first  diseased  and  then  mortified,  has  no  concern 
in  the  formation  of  the  new  bone.  It  may  be  the  periosteal  vessels, 
or  various  vessels  of  the  soft  parts  in  general,  they  argue ; but  it 
cannot  be  the  vessels  of  the  bone,  properly  so  called. 

This  doctrine,  though  supported  by  the  observations  and  experi- 
ments of  a number  of  able  observers,  has  nevertheless  been  strongly 
controverted,  first  by  Ludwig  and  Palletta,  and  afterwards  by 
Scarpa  and  Richerand. 

Ludwig  appears  to  have  early  maintained  that  the  new  soft  mass, 
by  which  the  loss  of  bone  was  to  be  supplied,  grew  or  sprouted 
from  the  sound  bone  ;*  and  Palletta,  from  the  facts  of  a case  which 
he  observed  with  great  care  in  the  year  1790,  arrived  at  the  con- 
clusion, that  the  growth  of  the  new  bone  proceeds  not  from  the  pe- 
riosteum, which  was  in  this  case  destroyed,  but  from  the  substance 
of  the  bone  itself.  In  the  case  now  adverted  to,  nekrosis  of  the 
left  tibia  was  induced  in  the  following  manner.  A man  of  50  was  ad- 
mitted into  the  hospital,  on  the  24th  December  1789,  for  an  ulcer 
of  the  leg,  which  progressively  denuded  the  whole  tibia,  so  that  the 
posterior  sirnface  of  the  bone  only  was  left  covered  by  soft  parts. 
A trihedral  portion  of  the  front  of  the  tibia,  five  Paris  inches 
long,  became  dead,  and  was  ejected.  After  this,  new  flesh  sprung 
from  the  surface  thus  exposed,  and  formed,  according  to  the  ac- 
count, a firm  bony  support,  such,  that  after  the  lapse  of  eight 
months  and  a few  days,  the  man  could  support  his  person  on  the 
limb.  He  was  gradually  I'ecovering  strength  until  September  1796, 
when  he  was  destroyed  by  an  attack  of  rose. 

’ Adversaria  Medico-Practica,  Vol.  III.  Pars  I.  p.  62.  Lipsise  1772.  ’ 


BONE. 


461 


The  recently  repaired  bone  was  of  a very  blood-red  colour, 
spongy,  crowded  everywhere  by  certain  smooth  nodes,  and  slightly 
bent  to  the  outer  or  fibular  side.  It  was  a white,  almost  cartila- 
ginous substance,  yet  sufficiently  strong,  which  Palletta  thinks 
must  have  become  firmer  in  time.  The  periosteum  was  not  thicker 
than  natural.  It  could  be  drawn  from  the  recent  bone,  and  ap- 
peared merely  laid  over  it.  The  bony  matter  proceeded  from  both 
extremities  of  the  tibia  to  mutual  contact.  Yet  the  meeting  portions 
did  not  coalesce,  but  were  uni  ted  as  it  were  by  intermediate  cartilage.* 

Scarpa,  who  adopts  this  doctrine,  maintains,  that  what  is  com- 
monly regarded  as  new  bone,  is  the  old  cortex  or  compact  tissue 
expanded  and  relaxed ; that  this,  by  a great  effort  of  nature,  is  every- 
where enlarged  and  becomes  spongy ; that  growing  inwardly  it  re- 
pairs the  loss  of  the  marrow,  and  swelling  outwardly  increases  the 
walls  of  the  bony  tube  ; that  hence  the  old  bone  is  enclosed,  as  it 
were,  in  a sheath,  which,  though  at  first  spongy,  soft,  and  flexible, 
becomes  hard  by  the  gradual  reception  of  earthy  particles,  and  at 
length  becomes  entirely  like  the  old  bone. 

Scarpa,  in  short,  first  assumes  or  maintains  in  the  living  tex- 
tures a vital  property  which  he  calls  the  expanding  faculty.  He 
then  maintains  on  the  strength  of  cases  of  nekrosis  and  various 
experiments,  that  no  reproduction  of  bone  takes  place  except  from 
callus  produced  from  ossific  fluid,  not  secreted  from  the  perios- 
teum or  the  cellular  tissue  in  the  medullary  membrane,  but  elabo- 
rated by  the  intimate  structure  of  the  bone,  and  which  is  effused 
sometimes  between  the  ends  of  the  broken  or  excised  bone,  some- 
times exudes  from  the  external  surface  of  bones,  and  being:  har- 
dened  in  both  situations,  assumes  the  bony  organic  character.! 

It  must  be  admitted  that  the  hypothesis  of  Troja  and  Weid- 
mann  labours  under  certain  difficulties ; and  in  exposing  these 
difficulties  and  the  objections  to  which  they  give  rise,  Scarpa  has 
been  more  successful  than  in  establishing  his  own  hypothesis, 
which  is  exposed  also  to  difficulties  perhaps  still  more  insur- 

• Exercitationes  Patliologicse,  Auctore  Joanne  Baptista  Palletta.  Mediolani,  1820. 
4io,  p.  28. 

t De  Anatome  et  Pathologia  Ossium,  Auctore  Antonio  Scarpa.  Turin,  1827,  p. 
82-  87-96. 

Verum  idcirco,  et  unicum  organon  elaborationis,  et  secretionis  succi  ossifici  est 
os  ipsum  ; neque  aliunde  quam  ex  universa  ossea  compage,  sive  laxa  ea  sit  et  reticulata, 
sive  dura  et  compacta,  liquor  ille  glutinosus  plasticus,  fila  trahens,  extillat,  qui  cum  in 
centro  fracturae,  turn  in  marginibus,  turn  in  extima  fracti  ossis  superficie  efFusus,  cogetur 
in  exiguas  rubras  carunculas,  dein  in  majora  cami  similia  tubercula,  demum  in  carti- 
laginem,  postremo  in  os  commutatur  et  calU  nomine  venit,  p.  104,  105. 


462 


GENERAL  AND  PATHOLOGICAL  ANATOMY, 


mountable  than  those  belonging  to  the  hypothesis  of  Weidmann. 

It  is  impossible  here  to  consider  all  the  facts  adduced  and  the  whole 
train  of  the  reasoning  employed  by  the  professor  of  Pavia.  It  is 
sufficient  to  observe,  that,  independent  of  the  violent  and  gratuitous 
nature  of  the  assumption  of  the  expanding  faculty,  which  he  as- 
cribes to  bone,  there  is  some  inconsistency  in  saying,  that  the  old 
cortex  is  expanded,  and  becoming  spongy,  and  advancing  inwards, 
forms  medullary  membrane,  and  swelling  outwardly  increases  the 
walls  of  the  bony  tube ; and  that  thus  the  old  bone  is  inclosed 
within  a sheath.  In  this  representation  the  old  bone  is  made  at 
once  to  inclose  and  to  be  inclosed. 

Another  objection  is  still  found  in  tbe  following  fact.  In  all  the 
instances  in  which  considerable  or  large  sequestra  have  come  away, 
how  does  it  happen  that  these  sequestra  resemble  so  closely  the 
shafts  or  portions  of  the  shafts  of  old  bones  as  they  do  ? Except- 
ing in  the  circumstance  of  their  broken,  irregular,  ulcerated  ex- 
tremities, and  the  carious  and  worm-eaten  appearance  of  the  surface, 
they  present  all  the  characters  of  an  old  or  dead  portion  of  a cy- 
lindrical bone.  It  is  to  be  observed,  that  from  the  moment  the  bone 
becomes  dead  from  whatever  cause,  whether  external  injury  or  in- 
flammation of  its  medullary  membrane,  instead  of  being  capable 
either  of  undergoing  this  expanding  process,  or  in  any  way  contri- 
buting to  the  formation  of  new  bony  substance,  it  is  a lifeless, 
inert  mass,  and  acts  as  a mechanical  irritant,  exciting  aud  main- 
taining, for  the  purpose  of  its  own  expulsion,  an  excessive  suppu- 
rative inflammation,  which  instead  of  promoting  and  facilitating  the 
formation  of  new  bone,  is  the  main  cause  above  all  others,  which 
retards,  impedes,  and  renders  impossible  the  necessary  secretion 
for  that  purpose.  It  is  a well-established  fact,  that  as  long  as  the 
old  bone  or  any  of  its  fragments  are  in  the  affected  limb,  the  depo- 
sition of  new  bone  is  so  much  retarded  and  often  rendered  im-  *■ 
practicable.  Conversely,  it  is  only  when  these  sources  of  irritation 
and  wasting  suppuration  are  withdrawn,  that  new  bone  begins  and 
proceeds  to  be  regularly  and  steadily  deposited.  The  irritative 
actions  are  excessive,  and  prevent  the  effusion  of  lymph  and  liquid 
callus  and  their  consolidation. 

A third  argument,  which  may  be  advanced  against  the  doctrine 
of  Scarpa,  is  the  following.  In  all  the  cases  of  nekrosis  with 
reproduction,  the  newly  formed  bony  mass  appears  to  be  so  cer- 
tainly the  result  of  the  operations  of  tissues  exterior  to  the  bone, 
that  it  is  impossible  to  understand,  how  the  old  bone  can  have  any 


BONE. 


463 


sliare  In  the  process  of  new  deposition.  The  reproduced  bone  is 
always,  a large,  thick,  shapeless  mass,  sometimes  imperfect,  that 
is  with  breaches  or  gaps  in  its  bony  walls,  irregular  on  the  surface, 
and  in  every  well  authenticated  case  three  or  four  times  the  diameter 
of  the  old  bone.  It  is  in  contact  with,  if  not  closely  invested  by 
inflamed  and  thickened  periosteum,  all  the  vessels  of  which  and 
the  surrounding  tissues  are  engaged  in  conveying  blood  and 
lymph  to  the  scene  of  effusion  and  deposition.  Lastly,  it  is  in  some 
parts  soft,  loose,  and  spongy,  in  others  firm  and  solid,  the  former 
being  the  most  recently  formed,  the  latter  the  last  deposited  portions. 

Scarpa  appears  to  have  adopted  the  idea  of  the  formation  of  bone 
in  nekrosis  from  the  phenomena  of  fractures,  in  which  certainly 
the  vessels  of  the  bony  fragments  are  instrumental  in  the  secretion 
and  modulation  of  liquid  callus.  It  may  be  admitted,  that  in  a cer- 
tain class  of  cases  of  what  may  be  called  fragmentary  or  limited 
nekrosis,  taking  place  chiefly  in  compound  fractures  and  gunshot 
wounds,  the  living  fragments  of  bone  may  present  materials  for 
the  formation  of  new  bony  matter.  But  this  is  a very  different 
process  from  that  which  takes  place  in  nekrosis  of  an  entire  bony 
shaft,  in  which  the  bone  is  already  dead,  in  the  midst  of  living  parts, 
and  consequently  cannot  be  supposed  to  be  the  agent  of  living  actions. 

Notwithstanding  these  objections,  the  hypothesis  of  Scarpa  has 
been  espoused  more  or  less  strongly  by  various  authors,  anatomical 
and  surgical,  who  have  also  apparently  confined  their  views  to  the 
phenomena  of  bones  comminuted  by  gunshot  wounds  or  com- 
pound fractures,  for  instance,  Leveille,  Richerand,  Jourdan,  and 
a few  others.  Richerand  in  particular, "regards  the  theory  of  Troja 
and  David  as  erroneous  in  this  respect,  that  It  represents  as  a uni- 
form law,  a phenomenon  which  takes  place  in  a small  number 
of  cases  only.  By  others  again,  as  Boyer,  Ribes,  and  Bedard,  at- 
tempts have  been  made  to  reconcile  the  two  hypotheses.  The 
attempt  seems  hopeless  and  impracticable,  unless  in  the  circum- 
stances already  specified,  in  which  portions  of  living  bone  are  really 
left  to  perform  the  duty  assigned.  In  cases  of  extensive  nekrosis 
of  a cylindrical  bone,  it  seems  a contradiction  in  terms  to  say  that 
the  dead  bone  can  reproduce  a living  one. 

In  1836,  Mr  Gulliver  examined  various  points  connected  with 
this  subject.  He  doubts  the  possibility  of  absorption  of  the  seques- 
trum, and  for  this  he  has  probably  good  reason.  He  undertakes 
to  prove  that  tissues,  at  least  bones,  being  dead,  possess  the  power 
amidst  living  tissues  of  attaching,  as  it  were,  from  the  blood  particles 


464 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


similar  to  themselves;  and  in  this  he  appears  to  confirm  certain  of 
the  views  of  Scarpa.* 

Lastly,  several  observations  by  Dr  Watson  Weinyss  favour  the 
inference,  that  the  living  parts  of  the  old  bone  do  not  contribute  to 
the  formation  of  the  new  one ; and  that  in  nehrosis,  the  periosteum 
is  the  agent  of  ossific  reproduction.! 

Regeneration  is  most  frequent  in  the  diaphyses  oi  the  cylindrical 
bones.  Many  cases  of  reproduction  of  the  humerus^  the  femur, 
and  especially  the  tihia^  are  on  record.  Of  the  ulna  three  only  are 
mentioned,  and  of  the  radius  only  one,  of  the  clavicle  one,  and  of 
the  scapula  one.  Of  the  lower  jaw,  regeneration,  either  partial  or 
total,  has  been  recorded  by  various  observers. 

The  flat  bones  of  the  skull  are  very  rarely  regenerated ; and  per- 
haps it  would  be  difficult  to  produce  an  authentic  and  unequivocal 
example,  unless  that  given  by  Weidmann  (pi.  xii.)  be  admitted. 
Mr  Russell,  however,  states  that  he  has  seen  instances  of  apertures 
of  the  cranial  bones  being  supplied  by  solid  matter  which,  to  his 
observation,  possessed  all  the  qualities  of  solid  bone.  This  never- 
theless resembles  more  the  reproduction  after  fracture  than  that 
after  nekrosis. 

The  short  or  cuboid  bones  appear  never  to  be  reproduced. 

3.  Spina  Ventosa. — Inflammation  of  the  medullary  web  of  the 
epiphyses  and  the  cuboid  or  short  bones  produces  very  different 
effects ; and  seems  occasionally  and  in  certain  circumstances  to  be 
the  cause  of  the  disease  so  vaguely  spoken  of  under  the  name  of 
Spina  Ventosa. 

The  history  of  this  disease  is  curious,  and  deserves  attention  frorn].- 
the  erroneous  notions  that  have  at  different  periods  prevailed  on  its 
correct  pathology. 

The  name  Spina  Ventosa,  or  flatulent,  or  wind  thorn  (DerWind- 
dorn),  was  employed  by  the  Arabian  surgeons  of  the  tenth  century  to 
designate  certain  painful  affections  of  the  bones,  which  were  probably 
not  always  of  the  same  kind,  and  which,  there  is  strong  reason  to 
believe,  did  not  depend  on  the  same  pathological  cause.  By  Rhazes,  - 
who  is  believed  first  to  have  described  the  disease,  it  is  represented'' 
to  consist  in  swelling,  erosion,  and  corruption  of  the  bone,  from  the 
presence  of  hot  humours  corroding  and  perforating  its  substance.J 
Similar  is  the  view  given  by  Avicenna,  who  represents  the  cause  of 

* On  Necrosis.  Medico-Chirurgical  Transactions,  Vol.  XXL  p.  1.  London,  1838. 
f Edinburgh  Medical  and  Surgical  Journal,  Vol.  LXIII.  p.  302.  Edinburgh,  1845. 

J Joannis  Freind,  M.  D.,  Opera  Omnia  Medica.  Londini,  173,3.  Folio.  Flistoria 
Medicina?.  Pars  Secunda,  p.  487. 


BONE. 


4-B5 

sphia  mntosa  to  be  sharp  humours  penetrating  to  the  bone  and  cor* 
roding  it;  and  the  approach  of  the  disease  to  be  indicated  by  pain 
in  the  joints,  yet  the  matter  of  the  disease  to  be  seated  in  the  bone. 
These  ideas,  which  are  derived  entirely  fi-om  external  symptoms, 
were  adopted  by  the  surgeons  of  the  16th  and  17  th  centuries,  with- 
out question  whether  they  were  accordant  with  fact  or  not.  Such 
were  the  doctrines  of  Joannes  de  Vigo  in  1513,  and  of  Pandolphi- 
nus  a century  later. 

Peter  de  Argellata,  indeed,  near  the  close  of  the  fifteenth  cen* 
tury,  gave  a more  definite  notion  of  the  distemper  by  saying,  that 
it  consisted  in  matter  collected  within  the  substance  of  a bone, 
either  from  weakness  of  assimilative  power  or  weakness  of  the 
member,  and  there  causing  abscess,  on  opening  which  by  incision 
the  whole  substance  of  the  bone  is  found  corrupted.* 

About  the  beginning  of  the  17th  century,  it  appears  to  have  been 
not  unusual  among  anatomists  and  surgeons  to  apply  the  term 
spina  ventosa  to  caries  of  the  smaller  spongy  bones.  Scultetus  tells 
us,  that  while  he  was  at  Padua,  studying  medicine  and  practising 
surgery,  he  saw  a young  nobleman,  who  had  been  for  several  months 
labouring  under  oedematous  swelling  of  the  left  hand,  which  ter- 
minated in  ulcerated  openings.  The  patient  was  then  submitted  to 
Spigelius,  at  that  time  professor  of  anatomy ; and  he,  finding,  on 
introducing  a probe,  the  bones  bare,  rough,  and  corrupted,  imme- 
diately said  that  the  disease  was  spina  ventosa.  As  Spigelius  died 
in  1625,  in  his  47th  year,  this  must  have  been  about  1620. 

Pandolpbinus,  who  was  a surgeon  at  Fermi,  published  in  1614  a 
treatise  on  the  disease,  which  was  by  Mercklin,  about  60  years  after, 
thought  worthy  of  a learned  and  elaborate  commentary.!  The 
commentary  is  now  more  valuable  than  the  text 

Marcus  Am’elius  Severinus  adopted  (1629)  partly  the  notions  of 
de  Argellata,  partly  those  of  Pandolphinus,  and  modified  the  doc- 
trine by  views  of  his  own.  “While  he  teaches  that  spina  ventosa 
consists  in  abscess  within  the  substance  of  the  bone,  he  adds  that  it 
takes  place  chiefly  if  not  solely  in  children,  and  is  mostly  found  in 
the  joints  and  ends  of  bones,  and  in  bones  of  spongy  cancellated 

* Petri  de  Argellata  Chirurgia.  Venetiis,  1480.  Lib.  V.  Tract,  xxii.  Cap.  2. 

“ Ventositas  spinse  est  ossis  corruptio  cum  partis  tumore  ac  intemperie,  ab  humore 
cormmpente  procedens.”  Josephi  Pandolphini  a Monte  IMartiano  IMedici  ac  Philo- 
sopbi  Tractatus  de  Ventositatis  Spinse  saevissimo  Morbo.  Revisus,  correctus  et  anno- 
tationibus  novisque  turn  proprii  turn  abenis  observationibus,  illustratus  a D.  Georgio 
Abrahamo  Mercklino  jun.  Med.  Noribergse.  Noribergse,  1674,  12mo.  Cap.  III. 


4GG 


GENERAL  AND  PATHOLOGICAL  ANATOJIY. 


texture.  To  me  he  appears  to  have  eonsidered  carious  and  strumous 
disease  of  the  small  joints,  especially  in  the  wrist  and  fingers  and  in 
the  tarsal  and  metatarsal  bones,  as  s-pina  ventosa  ; and  the  latter  he 
maintains  to  be  an  erroneous  and  improper  name.*  He  regards  it 
as  produced  in  the  manner  of  the  cold  or  congestive  inflammation. 

The  great  evil  of  all  essays  and  writings  in  those  days  was  con- 
founding the  remote,  efficient,  and  proximate  or  pathological  causes 
together,  and  rendering  all  their  doctrines  more  or  less  obscure  by 
mingling  ideas  on  the  generation  or  formation  of  a disease  with  its 
actual  nature.  This  is  the  case  not  only  with  Fandolphinus  and 
Severinus,  but  with  Peter  de  Marchettis,  who  has  left  a short  essay 
on  the  subject.  (1665.)  Amidst  these  notions,  however,  it  is  easy  to 
see  that  he  regards  the  pathological  characters  of  the  disease  as 
consisting  in  denudation,  roughness,  and  caries  of  the  bones  of  the 
wrist  or  metacarpus,  the  tarsus  or  metatarsus,  and  sometimes  of 
the  ends  of  the  radius  or  ulna,  the  tibia  or  fibula.  (1665).  He  also 
maintains  that  the  bone  is  first  affected,  and  then  the  periosteum.f 

If  any  doubt  could  be  entertained  as  to  the  locality  of  the  dis- 
ease assigned  by  de  Marchettis,  it  would  be  dissipated  by  this  cir- 
cumstance, that  he  tells  his  reader,  that  after  the  first  indications  of 
the  disease  is  pungent,  acute,  lancinating  pain,  without  swelling,  the 
matter  of  the  disease  then  raises  the  affected  joint  into  a swelling, 
at  first  soft,  loose,  and  indolent,  of  the  same  colour  with  the  skin ; 
and  afterwards  becoming  hard ; and  when  the  probe  is  introduced, 
the  bone  is  felt  corrupted  or  carious.  It  is  clear  that  he,  like  Spi- 
selius  and  Severinus,  describes  here  the  inflammation  of  the  arti- 
ticular  ends  of  bones  taking  place  in  strumous  persons.  This 
affection,  he  further  states,  he  observed  mostly  in  persons  of  both 
sexes  about  the  25  th  year. 

A doctrine  similar,  though  in  a more  decided  shape,  was  about 
the  same  time  taught  by  Paul  Ammann,  professor  at  Leipsic.  Ac- 
cording to  him,  spina  ventosa  is  a corruption,  abscess,  or  sphacelism 
in  a bone,  not  only  round  joints,  but  also  about  other  parts,  affect- 
ing the  substance  of  bones  earlier  than  the  periosteum,  equally  com- 
mon in  adults  as  in  children, — arising  from  inflammation,  some- 
times with  great  pain,  sometimes  with  dull  pain,  with  change  of  co- 

* De  Recondita  Abscessuum  Natura.  Lib.  V.  De  Paedarthrocace,  c.  III.  IV.  V. 
VI.  XL,  p.  103. 

Petri  de  Marchettis  Pataviiii  et  Observat.  Medico-Chirurg.  Sylloge.  Amstelodarai, 
1665,  p.  195,  196,  1.97. 


BONE. 


467 


lour  in  the  bone,  sometimes  with  hardness,  sometimes  with  soften- 
ing of  the  bone,  and  always  with  a thin  sanious  discharge.* * * § 

Next  in  this  series  may  be  placed  the  doctrines  of  Mercklin,  as 
given  in  his  commentary  on  the  treatise  of  Pandolphinus.  This 
author  collects  the  opinions  and  observations  of  all  his  predecessors 
and  contemporaries ; and,  though  it  be  not  easy  to  discover  his  own 
views,  yet,  upon  the  whole,  it  may  be  said  that  he  leans  most  to 
those  of  Ammann.  He  regards  the  disease  as  arising  from  inflam- 
mation in  the  substance  of  bones,  which  he  thinks  may  cause  either 
abscess  with  caries  or  sphacelus ; and  that  this  inflammation  may 
affect  any  portion  of  bones  or  any  order  of  bones;  and  may  arise  either 
from  scurvy,  the  venereal  poison,  or  the  presence  of  morbid  fluids.f 

The  nearest  approach  to  the  true  pathology  of  this  malady  was 
probably  made  by  Freind,  who  placed  the  primary  action  in  the 
marrow,  which  becoming  diseased  and  enlarged,  separates  the  outer 
lamella,  and  distends  the  periosteum  with  pain  and  swelling.  J We 
still  require,  nevertheless,  the  collateral  illustration  of  actual  cases 
and  dissections. 

Cheselden  observed,  in  1713,  that  matter  was  liable  to  be  formed 
within  the  large  medullary  cavities  of  the  cylindrical  bones ; and 
that  this  increasing  and  wanting  vent,  partly  by  corroding  and 
rendering  the  bone  cai'ious  and  partly  by  pressure,  tears  asunder 
the  strongest  bone  in  the  human  body  ; and  of  this  he  mentions  an 
example,  in  which  all  the  internal  hard  part  of  the  bone  containing 
the  medulla  was  separated  from  the  rest,  and  being  drawn  out 
through  the  plaee  where  the  external  caries  made  a vent,  the  pa- 
tient received  a perfect  cure.§  This  was  manifestly  a case  of  ne- 
krosis.  In  his  Osteographia,  published  in  1733,  containing  seve- 
ral views  of  diseased  bones,  especially  from  the  effects  of  mercury, 
he  gives,  in  his  49th  plate,  the  view  of  a sequestrum  of  the  os  humeri 
w'hich  had  been  removed  from  the  arm  of  a girl  of  1 3 ; and  in  his 
55th  plate,  another  figure  of  an  os  humeri,  both  reproduced,  and 
with  the  sequestrum  or  fragment  of  the  old  bone.§  These  he  men- 
tions without  seeming  to  consider  them  as  making  examples  of 
spina  ventosa. 

* Pauli  Ammann  Diss.  de  Spina  Ventosa.  Lipsise,  1674.  4to.  Cap.  ii. 

+ Joseph!  Pandolphini  Tractatus,  &c.  Cap.  v.  3,  p.  198,  et  passim.  Noriberg®, 
1674. 

J Joannis  Freind,  M.  D.,  Opera  Omnia  Medica.  Historia  Medicin®.  Pars  Secunda, 
p.  487.  Folio.  London,  1733. 

§ Osteographia.  By  tVilliam  Cheselden.  London,  1733.  Folio.  And  Anatomy 
of  the  Human  Body,  12th  edition.  London,  1784.  P.40. 


4G8 


GENERAL  AND  PATHOLOGICAL  ANATOLIY. 


In  1742  and  1743,  Cornelius  Trioen,  a physician-surgeon  af 
Leyden,  published  a series  of  medico -chirurgical  cases,  containing 
also  observations  on  spina  centosa.  This  he  distinguishes  into 
three  forms ; spina  ventosa,  spina  venenosa^  and  spina  mitior.  After 
stating  as  a general  definition  that  spina  ventosa  consists  in  expan- 
sion or  distension  of  the  bony  substance,  and  a sort  of  separation  of 
the  smooth  or  compact  tissue  of  the  bone  and  its  tuhiili  from  the 
substance,  that  is  the  cancellated  tissue  of  the  bone,  by  which  the 
hone  and  the  incumbent  soft  parts  are  enlarged  much  beyond  their 
wonted  diameter ; he  adds,  that  the  first  is  that  in  which  the  texture 
of  the  bone  is  not  penetrated  with  purulent  matter  or  other  fluids, 
and  that  the  threatened  rupture  of  the  bone  is  anticipated  by  death, 
while  the  bony  substance  may  be  inflated  like  a large  globe.  Of 
this  he  gives  one  instance  in  which  the  lower  extremity  of  the  femur 
is  certainly  expanded  in  this  fashion  into  a large  irregularly  globu- 
lar tumour  (p.  106,  108,)  yet  without  the  presence  of  ichor,  puru- 
lent matter,  or  offensive  smell,  and  in  which  the  patient  was  de- 
stroyed by  repeated  hemorrhage.  It  must  be  allowed  that  the 
figure  given  of  this  case  resembles  much  that  kind  of  disease  to 
which  several  surgeons  in  recent  times  have  applied  the  name  of 
Spina  ventosa. 

The  second  form  of  the  disease  admitted  by  Trioen  corresponds, 
it  appears  to  me,  with  caries  as  it  shows  itself  in  the  short  or  irre- 
gular bones  of  spongy  cancellated  tissue;  for  instance  the  hones  of 
the  carpus  and  metacarpus,  and  the  tarsus  and  metatarsus,  and  the 
vertebrae.  These  he  allows  to  be  attended  with  swelling,  small, 
livid,  deep  ulcers,  admitting  the  probe  to  rough,  denuded,  often 
softened  bones,  and  as  occurring  mostly  in  young  persons  of  deli- 
cate constitution,  corresponding  to  the  Paedarthrocace  of  Severinus; 

(p.  111.) 

The  third  form  of  the  disease,  which  he  terms  spina  mitior,  corre- 
sponds, if  we  judge  from  the  example  of  it  adduced,  with  nekrosis. 
He  describes  it  as  affecting  the  middle  or  hard  substance  of  bones, 
and  after  inducing  swelling,  causing  the  separation  of  the  compact 
substance  like  plates,  with  discharge  of  matter,  yet  without  fcetor. 
Of  this  he  gives  three  examples  taking  place  in  the  tibia,  in  each; 
of  which  the  fragments  of  dead  bone  were  separated  and  expelled,- 
with  recovery  of  the  patient.  (P.  115,  118.)* 

It  appears,  therefore,  that  Trioen  knew  and  described  under  the- 

* Comelii  Trioen  Medicinae  Doctoris  Observationum  Medico  Chirurgicarum  Fasci- 
culus. Lugduni  Batavorum,  1743.  4to. 

1 


BOXE. 


469 


ssrne  iiaaie  of  sp'ma  ventosa  three  forms  of  disease  of  the  bones ; 
the  first  enlargement  and  expansion  of  the  extremities  of  the  long 
bones,  the  second  caries  or  chronic  strumous  inflammation  of  the 
short  irregular  bones,  and  the  third  nekrosis,  as  it  appears  in'  the 
cylindrical  bones. 

In  1746,  there  was  read  to  the  Royal  Society  by  the  late  Claudius 
Amyand,  Sergeant-Surgeon  to  the  King,  a paper  containing  observa- 
tions on  spina  ventosa,  and  giving  in  illustration  two  instances  of  ne- 
hrosis,  one  in  the  os  humeri  of  a man  of  22,  aiiother  in  the  same  bone 
of  a man  of  26.  Mr  Amyand  begins  by  observing,  that  “ what  prac- 
titioners generally  understand  by  the  spina  ventosa  is  a caries  in  the 
bone  from  the  extravasation  of  some  sharp  juices  within  it  relaxing 
the  tone  of  the  fibres,  and  swelling  and  increasing  its  bulk  beyond 
the  natural  bounds.”  He  farther  allows  that  in  certain  cases  the 
cariosity  is  encrusted  and  covered  with  an  exostosis,  that  is,  with 
bony  matter ; that  when  the  bone  swells,  the  nutritious  fluid  is  de- 
posited outside,  and  forms  callus  ; that  in  certain  cases,  in  the  first 
stage  of  the  disease,  purulent  matter  lodged  within  the  substance  or 
cavities  of  the  bone,  causes  some  exfoliation  or  detachment  of  it ; 
and  that,  in  the  last  stage  of  the  disease,  the  bone  is  perforated  with 
holes,  tubulous  cavities,  and  fistulous  openings;  and  that  it  is  highly 
probable  that  a suppurated  phlegmon  in  the  marrow  was  the  ori- 
ginal cause  of  the  spina  ventosa  in  the  two  cases  recorded. 

From  these  facts  it  appears  that  Mr  Amyand  describes  as  spina 
ventosa  the  disease  now  known  by  the  name  of  nekrosis;  that  he 
rightly  inferred  that  this  disease,  nekrosis^  arises  from  inflammation 
of  the  medullary  membrane  of  cylindrical  bones;  that  he  was 
aware  that  new  bony  matter  was  formed  outside  the  old  or  original, 
but  diseased  bone ; and  that  the  original  or  diseased  bone  was  ex- 
foliated and  detached.* 

In  1751,  the  Treatise  on  the  Diseases  of  Bones,  by  M.  Du  Ver- 
ney,  appeared.  Though  this  surgeon  noticed  various  cases  of  ne~ 
crosis,  yet  he  does  not  mention  spina  ventosa.  The  editor,  however, 
in  his  preface,  mentions  shortly  that  inflammation  of  the  medulla 
produces  pain,  heat,  throbbing,  swelling,  abscess,  caries  of  a bad 
character,  and  even  spina  ventosa,  if  the  cause  be  internal ; and 
that  the  corruption  of  the  medulla  without  external  wound,  or  that 
which  is  produced  by  an  internal  cause,  is  called  spina  ventosa.,  in 
consequence  of  the  corrosion  and  destruction  of  the  bone  attended 

• Some  Observations  on  the  Spina  Ventosa  ; l>y  the  late  Claudius  Amyand,  Esq. 
F.  R.  S.  Sergeant- Surgeon  to  his  Majes^v.  Phil.  Trans.  1746,  Vol.  XLI V.  p.  I.  p.  193, 
London,  1748. 


470 


GENERAL  AND  PAIIIOLOGICAL  ANATOMY. 


with  pungent  pain  and  swelling.* * * §  There  is  good  reason  to  think 
that  the  author  has  in  view  some  of  the  multiplied  eflfects  of  second- 
ary syphilis  or  mercurial  disease. 

It  appears,  indeed,  for  a long  time,  to  have  been  a common  prac- 
tice to  regard  as  sf  ina  ventosa  many  of  these  affections  of  the  bones, 
which  arise  either  from  the  operation  of  the  syphilitic  poison,  or  the 
hurtful  effects  of  mercurial  medicines;  and  I think  it  certain,  that 
many  of  the  painful  affections  of  bones,  dependent  on  one  or  other 
of  these  causes,  were  regarded  as  instances  of  spina  ventosa.  Such 
appear  to  have  been  the  ideas  of  the  first  Monro,  Cheselden,  and, 
at  a later  period,  Schlichting,  who  states  that  he  observed  the  spina 
ventosa  to  be  very  like  the  venereal  disease,  and  to  corrupt  the  hu- 
mours and  vessels  of  the  body.f  Cheston,  (1766,)  who  was  desirous 
chiefly  to  distinguish  the  disease  from  white  swelling,  after  refer- 
ring to  Avicenna  and  Mercklin,  concludes  with  them  that  it  begins 
originally  within  the  bone,  which  is  more  or  less  enlarged.  It  is 
evident,  however,  that  he  had  not  formed  any  very  clear  or  distinct 
idea  of  the  nature  of  the  maladj’.  j 

Warner  places  it  (1756,  1784)  in  the  marrow  and  vessels  of  the 
bone,§  (p.  322);  and  Bromfield,  we  have  seen,  (1773)  regards  it 
as  abscess  of  the  marrow,  without  appearing  to  be  aware  of  the  re- 
lation between  this  and  nelirosis\.  (P.  20-22). 

It  is  not  wonderful,  therefore,  that  Augustin,  who  published  in 
1797  a learned  treatise  on  the  subject,  complains  of  the  confused 
ideas  and  contradictory  views  given  on  this  disease.  He  had  en- 
deavoured, after  studying  the  preparations  in  the  museums  at  Ber- 
lin, Halle,  and  Goettingen,  to  form  a distinct  and  precise  notion  of 
the  disease  ; and  he  has  certainly  added  to  our  knowledge.  Yet 
it  cannot  be  said  that  his  distinctions  are  so  clear  and  precise  as 
might  have  been  expected.  At  that  time  it  appears  that  several 
teachers  called  every  internal  caries  by  the  name  of  spina  ventosa  ; 
others  confounded  it  with  every  sort  of  sv/elling  in  bones. 

Spina  ventosa  Augustin  represents  to  consist  in  internal  inflam- 

* Traite  des  Maladies  des  Os.  Par  M.  Du  Verney,  M.  D.  &c.  Paris,  1751,  Tom. 
I,  Preface.  VII. 

+ Philosophical  Transactions.  London,  1742.  No.  466. 

Pathological  Observations  and  Inquiries  on  Surgery  from  the  Dissection  of  Mor- 
Ijid  Bodies.  By  Richard  Browne  Cheston,  Sui-geon  to  the  Gloucester  Infirmary. 
Gloucester,  1766,  4to.  p.  117. 

§ Cases  in  Surgery,  with  Introductions,  Operations,  and  Remarks.  By  Joseph 
Warner,  F.  R.  S.,  Senior  Surgeon  to  Guy’s  Hospital.  London,  1760  and  1784. 

II  Chirurgical  Observations  and  Cases.  By  William  Bromfield,  Surgeon  to  Her  Ma- 
jesty, &c.  London,  1773.  Vol.  II.  pp.  20  and  22. 


BONE. 


471 


mat!  on  of  a bone  with  swelling,  universal  in  a small  bone,  partial 
in  a large  one,  causing  the  greatest  pain,  terminating  successively 
in  swelling  of  the  soft  parts,  not  unfrequently  in  fistulous  ulcers, 
and  caries,  by  all  which  the  aflfected  bone  is  converted  into  a large, 
irregular,  and  tuberous  mass  of  hard  or  highly  corrupted  struc- 
ture. From  caries  he  distinguishes  it  by  the  presence  of  swelling 
or  enlargement,  and  by  the  absence  of  ulceration  ; and  fi’om  exos- 
tosis and  hyperostosis  by  the  parietes  of  the  bone  being  separated  and 
destroyed.* * * § 

Among  the  four  figures  given  by  Augustin  to  elucidate  the  cha- 
racter and  nature  of  the  disorder,  it  appears  that,  with  great  irre- 
gularity and  spiny  roughness  of  the  bones  affected,  and  enlarge- 
ment, there  is  deposition  of  bone  in  irregular  forms  and  masses. 
It  is  in  these  an  abnormal  nutrition  or  misnutrition  in  the  bony 
texture.  In  one,  (fig.  3,)  a tibia,  there  is  enlargement  and  separa- 
tion of  the  walls  of  the  bone,  and  irregular  exostotic  deposits ; and 
in  another,  (fig.  4,)  the  lower  third  of  the  osfemoris  is  enlarged  in- 
to a great  irregular  mass,  very  irregular  on  its  surface,  and  with 
manifest  indications  of  new  bony  depositf 

These  views,  nevertheless,  appear  to  have  been  overlooked  by 
Petit,  Bordenave,  Portal,  and  others,  who,  regarding  it  as  a variety 
of  exostosis  occurring  in  the  scrofulous,  and  complicated  with^sup- 
puration  in  the  substance  of  the  bone,  by  a wish  to  simplify,  have 
rendered  the  subject  moi’e  complex.  Scarpa,  especially  in  his  Com- 
mentaries, maintains  that  spina  ventosa  differs  in  degree  only  from 
exostosis  and  osteo-sarcoma.\  The  opinion  of  Bichat  is  not  very 
distinct.§  That  of  Monteggia  and  Pal]etta||  is  much  more  explicit. 
The  former  represents  it  as  commencing  in  the  marrow,  which  in- 
flames slowly,  swells  and  wastes,  or  passes  into  a slow  suppm-ation, 
distending  the  parietes  of  the  bone  all  round,  and  then  bursting  its 
compact  shell,  giving  vent  to  the  medullary  sanies,  and  causing  the 
inflammation  and  suppuration  of  the  soft  parts,  at  the  bottom  of 
which  the  bone  is  found  bare  and  carious,  or  covered  with  fungous 
gi’anulations,  but  with  one  or  more  orifices  penetrating  into  the 
medullary  cavity.lf 

* De  Spina  Ventosa  Ossium.  Scripsit  Fridericus  Ludovicus  Augustin,  Med.  et 
Chirurgise  Doctor.  Halae,  1797,  4to.  Accedunt  leones  IV.  § 4,  § 5,  g 7,  § 34. 

-f-  De  Spina  Ventosa  Ossium,  § 27,  § 28,  § 29. 

J De  Anatonie  et  Pathologia  Ossium,  p.  76  and  78.  Ticini,  1827,  4to. 

§ Anatomie  Generate,  Tome  III.  p.  112. 

II  Exercitationes  Patholog.  Mediolani,  1820,  p.  120. 

TI  Istituzione  Chirurgiche,  Vol.  II.  64.5,  p.  275. 


472 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


This  view  errs  only  in  placing  the  disease  in  the  marrow,  which, 
as  an  inorganic  secretion,  is  incapable  of  orgasm,  healthy  or  mor- 
bid. The  true  agent  of  the  process  is  the  vascular  medullary  web, 
especially  of  the  epiphysis^  of  such  bones  as  the  vertebrse,  the  car- 
pal and  tarsal  bones,  and  the  phalanges.  The  cancellated  arrange- 
ment of  the  osseous  matter  and  of  its  medullary  web  in  these  bones 
explains  the  progress  and  phenomena  of  the  disorder. 

Palletta  adopts  the  distinctions  of  Trioen ; and  admits,  in  true 
spina  ventosa,  expansion  of  the  bony  walls.  Spina  mitior  he  allows 
to  be  the  same  as  nekrosis. 

Though  various  modern  surgeons  have  directed  their  attention 
to  this  subject,  it  is  still  surrounded  with  confusion  and  uncertainty. 
Some  allow  that  the  disease  does  not  affect  the  epiphyses,  but  the 
shafts  of  the  bones,  and  admit,  however,  the  expanding  process. 
Dupuytren,  who  was  aware  of  the  confusion  in  the  application  of 
the  term,  has  not,  however,  done  much  to  remove  it.  From  the 
few  cases  which  he  records  under  this  head,  it  appears  that  the  dis- 
ease affects  the  head  of  the  humerus  by  enlargement  a,nd  expansion 
of  the  osseous  walls,  and  the  phalanges  and  metacarpal  bones  in 
the  same  manner.  He  admits  that  the  disease  is  seated  in  the  ca- 
vity of  the  bone ; that  in  certain  cases  there  is  a deposit  of  cancer- 
ous matter  which  distends  the  bone ; that  it  is  an  affection  of  the 
medullary  membrane  ; and  that  there  is  secreted  a new  substance, 
fungous,  gelatiniform,  gray,  yellow,  lardaceous,  sometimes  gypse- 
ous and  serous.* 

It  is  clear,  from  the  account  now  given,  that  this  eminent  sur- 
geon had  formed  on  the  intimate  nature  of  this  disease  no  distinct 
or  precise  ideas  ; and  he  has  left  the  subject  in  as  great  confusion 
as  when  he  found  it.  The  subject  is  certainly  unsettled  from  the 
contradictory  and  inaccurate  manner  in  which  the  term  has  been 
employed. 

From  the  facts  here  adduced,  the  following  conclusions  may  be 
established. 

IsA  It  appears  that  the  early  writers  on  spina  ventosa  had  no 
distinct  or  precise  notions  on  its  characters  and  nature,  and  that 
most  of  them,  like  Vigo,  de  Argellata,  Pandolphinus,  and  Severinus, 
regarded  as  spina  ventosa,  caries  of  the  articular  ends  of  bones,  -, 
chiefly  dependent  on  chronic  inflammation  of  the  medullary  mem- 
brane. 

^ Lecons  Orales  de  Clinique  Chirurgicale.  Tome  Deuxieme,  Article  XII.  p.  26,S — 
275.  Paris,  1839. 


BONE. 


473 


2d.  It  appears  that  several  surgeons  during  the  18th  century, 
as  Trioen,  Amyand,  and  Bromfield,  when  the  knowledge  of  morbid 
processes  was  deriving  advantage  from  anatomical  enquiry,  regarded 
as  instances  of  spina  ventosa,  cases  which  were  examples  of  nekrosis. 

3(7.  It  appears  that,  up  to  the  present  time,  very  great  confusion 
and  inaccuracy  prevails  as  to  the  exact  import  of  the  term  spina 
ventosa,  which  with  one  set  of  observers  means  an  ordinary  though 
morbid  affection  of  bone,  and  with  others  is  employed  to  designate 
a malignant  or  heterologous  disease  of  bone. 

And  47A.  It  appears,  nevertheless,  that  all  agree  in  considering 
enlargement  of  the  bone  and  expansion  of  its  bony  walls  as  a uni- 
form result. 

If  we  look  to  specimens  in  collections,  we  find  that  the  opinions 
of  surgeons  are  by  no  means  the  same,  and  present  much  dis- 
cordance. Thus  we  find,  in  one  pathological  museum,  marked 
as  spina  ventosa,  a greatly  enlarged  end  of  a long  bone,  the  bony 
wall  extruded,  and  a large  irregular  cavity  formed  internally.  In 
other  instances,  we  find  placed  under  the  head  of  spina  ventosa  in- 
stances of  enlargement  of  the  metacarpal  bones  and  phalanges.  In 
others,  again,  we  find  bones  with  great  enlargements,  and  covered 
with  numerous  rough  spines  and  spiculce,  considered  as  spina  ven- 
tosa. In  short,  every  disease  of  bone  not  previously  referred  to  a 
definite  place,  is  accounted  by  different  individuals  spina  ventosa. 

From  the  specimens  which  I have  examined,  I think  that  enlarge- 
ment of  the  bone  and  expansion  of  its  osseous  walls  must  be  admit- 
ted as  one  character.  Two  points,  however,  remain  to  be  deter- 
mined, which  is  the  agent  of  this  enlargement ; and  are  the  new  de- 
posits analogous  or  heterologous  ? In  general  I think  that  they 
are  analogous,  that  its  products  are  those  of  inflammatory  action  of 
a peculiar  kind,  or  at  most  of  misnutrition.  They  do  not,  in  legiti- 
mate Apma  aen76)5(J!,  appear  to  be  scirrhous  or  cancerous.  The  fungous 
granulations  appear  to  be  the  product  of  the  medullary  web  in 
these  particular  circumstances. 

That  this  is  the  seat  of  its  action  is  to  be  inferred  first  from  the  phe- 
nomena of  the  disease ; and  secondly,  from  its  effects,  as  seen  in  dis- 
eased bones.  Spina  ventosa  never  occurs  in  a bone  with  distinct  me- 
dullary canal,  unless  at  the  epiphyses,  where  the  structure  is  cancel- 
lated. When  it  takes  place  in  these  situations,  it  first  induces  en- 
largement of  the  epiphyses,  with  extreme  pain  deep  in  the  bone. 
Soon  after  the  periosteum  becomes  thick  and  swelled ; and  in  no 
long  time  sanious  matter  is  found  beneath  it  issuing  from  the  can- 


474 


GENERAL  AND  RATHOLOGICAL  ANATOMY. 


ce///,  which  are  then  softened,  partially  destroyed,  and  excavated. 
If  in  this  state  such  a bone  be  examined,  the  broken  eancelli  are 
filled  with  a reddish,  soft,  spongy  vascular  mass,  producing  flabby 
granulations  passim^  and  secreting  bloody  sanious  fluid.  The 
compact  shell  is  partly  destroyed  by  irregular  ulceration,  and  part- 
ly extruded  by  the  distending  force  of  the  swelled  medullary  web. 
The  diseased  epiphysis  then  presents  a large  irregular  anfractuous 
cavern  filled  with  soft  spongy  substance,  which  is  either  the  web 
itself,  or  the  new  products  which  its  inflammation  has  generated.* 
In  this  manner  it  is  frequent  in  the  upper  end  of  the  tibia,  or  the 
lower  end  of  the  femur,  or  in  the  extremities  of  the  radius  or  ulna. 

With  deference,  therefore,  to  the  observation  and  assiduity  of  Mr 
Howship,  I cannot  agree  with  this  author,  that  spina  ventosa  is  an 
enlargement  affecting  the  cylindrical  bones,  unless  with  the  limita- 
tion above  stated.  The  only  cylindrical  bones  in  which  its  occur- 
rence may  give  colour  to  this  opinion  are  the  phalanges.  These, 
however,  have  no  distinct  medullary  cavity,  and  resemble  in  all  re- 
spects the  epiphyses  and  the  short  irregular  bones  in  general.  In 
these  the  disease  occurs  in  children  and  young  persons.  It  occurs 
also  in  the  lower  jaw,  and  occasionally  in  the  vertebrae. 

7.  Enosf.osis.  Medullary  Exostosis. — To  this  head  I do  not  re- 
fer the  examples  quoted  by  Houstet  from  Ruysch,  Cheselden,  and 
Daubenton,  and  which  I conceive  belong  to  necrosis.  There  are 
nevertheless  instances  of  cylindrical  bones  having  an  accretion  of 
bony  or  osteo-colloid  matter  deposited  in  their  interior,  to  such  an 
extent  as  at  once  to  enlarge  much  the  dimensions  of  the  bone,  and 
obliterate  the  medullary  cavity.  Examples  of  this  are  recorded  by 
Cheselden,t  Mery,|  Tripier,  Houstet, § and  J.  Bell ; and  Sir  A. 
Cooper  describes  the  disease  at  length  under  the  name  exostosis  of 
the  medullary  membrane.  According  to  the  observation  of  this 
experienced  surgeon,  the  disease  occurs  in  two  forms,  the  fungous 
and  the  cartilaginous.  Both  originate  from  the  medullary  web ; 
both  produce  enlargement,  expansion,  softening,  and  separation  of 
the  osseous  walls ; and  both  ultimately  terminate  in  ulcerative  ab- 
sorption of  the  affected  bone.  In  certain  circumstances,  however, 
they  differ  from  each  other.  The  fungous  exostosis  consists  of  lo- 

* See  Observations  on  the  Morbid  Appearances  and  Structure  of  Bones,  &c.  By 
John  Howship,  Esq.  Med.  Chir.  Tr.  Vol.  x.  p.  176,  and  several  fine  delineations  of  the- 
disease. 

-h  Osteographia,  p.  53. 

J Mem.  de  I’Academie  des  Sciences,  1706,  p.  245. 

§ Mem.  de  I’Acad.  Roy.  Chimrgie,  Tome  hi.  p.  130. 

1 


BONE. 


475 


bulated  masses  of  soft,  spongy,  vascular  substance  like  fat,  brain, 
or  clotted  blood,  which  emits  malignant and  discharges  blood- 
coloured  serum.  After  some  time  it  not  only  distends,  separates, 
and  destroys  the  bone,  but  it  undergoes  an  alternate  process  of 
sloughing  and  hemorrhage.  Though,  in  compliance  with  the  views 
of  Sir  A.  Cooper,  I placed  it  under  this  head,  it  is  scarcely  entitled 
to  the  character  of  enostoxis  or  exostosis,  but  is  manifestly  of  the 
nature  of  the  encephaloid  tumour.  The  cartilaginous,  or  genuine 
enostosis,  consists  of  masses  of  firm  chondrodesmoid  structure, 
whitish-red  or  gray,  producing  by  its  enlargement  progressive  se- 
paration and  destruction  of  the  bone,  but  not  possessing  the  fun- 
gating  or  malignant  tendency.* 

M.  A.  Severinus,  Mery,  and  Mr  J.  Bell  have  described  a va- 
riety of  monstrous  enlargement  of  the  bones  of  the  hand,  which  I 
think  is  to  be  viewed  as  belonging  to  the  head  of  enostosis.  Though 
they  are  termed  tumours  of  the  phalanges,  it  is  impossible  to  doubt, 
from  perusing  the  authentic  description  of  Mery  especially,  that  the 
disease  consisted  of  inordinate  enlargement  of  the  ends  or  articular 
heads  of  the  phalanges.!  This  enlargement  was  confined  to  the 
ends  of  the  metacarpal  and  middle  row.  The  shell  of  the  bones 
was  extenuated,  and  in  some  parts  broken.  The  interior  structure 
consisted  of  irregular  bony  masses,  fibrous  and  cellular,  or  caver- 
nous, containing  reddish  semifluid  jelly.  The  contiguous  articula- 
tions were  ankylosed.  These  changes  depend  doubtless  on  mor- 
bid action  of  the  medullary  web.  Any  change  in  the  structure  of 
the  bone  and  periosteum  in  such  circumstances  is  secondary.  A 
similar  case  is  given  by  Scarpa,  (Tab.  6.) 

h.  Padartlirokahe.  Osteo-arthritis.  Joint-iil  of  Children. — This 
name  was  applied  by  Pandolphinus,  Marcus  Aurelius  Severinus, 
Mercklin,  and  various  other  authors  of  the  17th  century,  to  designate 
a disease  which  they  conceived  to  be  the  same  with  spina  ventosa. 
From  the  facts  already  adduced  on  this  head,  it  is  clear  that  they 
committed  a great  mistake,  and  that  they  confounded  two  diseases 
which  are  essentially  different.  It  is  evident  that  the  disease  which 
they  most  frequently  saw,  was  that  in  which  the  articular  ends  of 
the  bones,  more  especially  the  small  bones  of  the  extremities,  be- 
come affected  with  caries,  in  consequence  of  previous  disease  of  the 
synovial  membrane,  or  chronic  inflammation  of  the  medullary  mem- 

* Surgical  Essays  by  Sir  A.  Cooper.  Part  i.  Pp.  165-173. 

-|-  Memoires  de  PAcad.  des  Sciences,  1720,  p.  583.  See  also  J.  Bell's  Principles 

Surgery,  Vol.  iii.  pp.  73  and  80. 


47fi 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


brane  of  the  epiphyses.  The  last  circumstance,  nevertheless,  is  of 
small  moment.  The  main  fact  to  be  attended  to  is,  that  the  arti- 
cular ends  of  the  small  bones  of  the  extremities  are  liable  to  be- 
come denuded  of  their  membranous  coverings,  to  be  rough  and 
softened  on  their  surface,  to  be  swelled,  and  discharge  a bloody, 
serous  matter,  and  that  no  tendency  to  eject  the  diseased  portion 
in  mass  is  exhibited ; while  minute  atoms  of  the  bone  are  removed 
by  ulceration  and  carried  away  in  the  discharges. 

This  disease  may  originate  either  in  the  synovial  membrane  of 
the  articulation,  and  proceed  thence  to  the  subjacent  cancellated 
tissue  of  the  bone,  or,  beginning  in  the  medullary  membrane  of  the 
cancellated  tissue,  it  proceeds  outwards  to  the  synovial  membrane, 
which  is  affected  with  secondary  inflammation  and  ulceration. 

This  sort  of  disorder  may  affect  any  articulation  in  the  whole 
body.  But  those,  in  which  it  is  most  usually  observed,  are  the  ar- 
ticular surfaces  of  the  carpal  and  tarsal  bones,  the  articular  ends 
of  the  metacarpal  and  metatarsal  bones,  and  those  of  the  phalanges 
of  the  fingers  and  toes.  A considerable  number  of  examples  of 
the  disease  in  the  bones  of  the  wrist,  metacarpus,  and  fingers,  I 
have  seen  in  young  females ; and  I think,  that  in  them  it  is  more 
frequent  than  in  males. 

The  first  indication  of  the  approach  and  presence  of  the  disease 

is  sw'elling,  generally  of  a puffy  character,  over  the  joint  attacked.^ 
Pain  is  also  felt;  and  the  surface  is  in  general  hot  and  red.  Th^S 
disease,  however,  whether  originating  in  the  medullary  tissue  or!™ 
in  the  synovial  membrane,  proceeds  so  rapidly  and  insidiously,  that|p 
often  the  whole  articular  end  of  one  bone,  if  not  both  of  those  of 
the  articulation,  is  stripped  of  its  covering,  rough,  and  irregular, 
before  the  true  nature  of  the  malady  is  suspected.  I 

The  cancelli  thus  attacked  are  softened  and  reddened;  and  the  part 
immediately  affected  is  manifestly  enlarged.  In  cases  where  opportu- 
nities of  inspecting  the  bones  have  been  afforded,  they  are  found  f- 
dcnuded  of  synovial  membrane,  cartilage,  and  periosteum.  Their 
exposed  surface  is  rendered  irregular  by  numerous  holes  or  cavities 
varying  in  size;  and  from  which  is  seen  issuing  a reddish  or  brown-M 
coloured  sero-purulent  matter,  with  which  also  the  cancelli  or  lattice-^ 
work  of  the  bone  is  filled. 

The  whole  of  this  destruction  is  occasioned  most  commonly  b)™ 
inflammation  of  the  cancellated  medullary  membrane,  in  some  in- 
stances by  that  of  the  synovial  membrane.  Yet,  notwithstanding 
the  nature  of  the  parts  affected,  recoveries  are  occasionally  observed^ 


BONE. 


477 


to  take  place.  Adhesive  inflammation  comes  on ; lymph  is  eff’used ; 
a stop  is  put  to  the  disorganizing  action ; and  new  ossific  matter 
being  formed,  sometimes  with  the  preservation  of  the  articulation, 
sometimes  with  ankylosis,  partial  or  complete,  the  disease  altogether 
disappears. 

The  disease  is  liable  to  afiect  the  vertehrcB,  and  often  does  affect 
them.  There,  however,  it  is  much  less  likely  to  subside.  In  short, 
as  it  most  frequently  attacks  bones  which  have  cancellated  tissue, 
as  the  short  bones  and  the  vertebrae,  so  it  in  them  causes  most  ha- 
voc, and  is  least  likely  to  undergo  this  spontaneous  cure. 

This  disease  affects  mostly  and  preferably  young  persons.  It 
begins  to  appear  about  the  6th  or  7 th  year ; and  may  take  place 
at  any  time  between  that  and  the  21st  year.  After  the  latter  pe- 
riod it  is  much  less  common,  but  may  take  place,  especially  in  fe- 
males. I have  seen  it,  nevertheless,  in  some  rare  cases,  affecting 
the  bones  of  the  feet  in  men  above  40  and  50. 

c.  The  third  source  of  disease  in  the  osseous  texture  are  the  arti- 
cular synovial  membranes  and  cartilages.  Inflammation  of  the 
first  soon  passes  to  the  second,  in  which  it  causes  erosion  or  ulce- 
rative absorption.  From  the  cartilage  this  may  proceed  progres- 
sively to  the  epiphyses,  the  upper  surface  of  which  is  sooner  or 
later  excavated  into  numerous  holes  or  caverns  of  various  size  and 
shape.  This  process,  which  I refer  to  the  vessels  passing  from  the 
cartilage  to  the  medullary  web  of  the  epiphyses,  is  accompanied 
with  deep-seated  aching  pain,  particularly  distressing  during  the 
night.  It  is  very  common  in  that  form  of  disease  of  the  joints 
which  arises  from  inflammation  of  the  synovial  membrane  and  car- 
tilages ; and  several  instances  are  recorded  by  authors.*  It  occurs 
in  the  hip-joint  and  knee-joint  especially,  and  is  one  of  the  preli- 
minary steps  to  ankylosis.  I have  seen  this  take  place  in  the  knee- 
joint,'and  have  ascertained  the  point  by  dissection. 

This  also  is  one  of  the  modes  in  M'hich  the  vertebrae  become  ca- 
rious. Chronic  inflammation  affects  the  synovial  membrane  and 
cartilages  of  an  oblique  process,  and  passing  into  the  bone  produces 
ulceration  and  carious  excavatious.  This  process  not  unfrequently 
causes  in  the  incumbent  and  contiguous  textures,  irritative  suppu- 
ration constituting  an  extensive  abscess,  which,  according  to  cir- 
cumstances, may  take  the  anterior,  the  posterior,  or  the  inferior  di- 

* See  Cheston,  who  delineates  two  examples  of  it,  and  is  at  some  pains  to  distin- 
gnish  it  from  sj^ina  ventosa. 


478 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


rectioii.  As  the  original  seat  of  the  disease  is  generally  the  lower 
dorsal  or  upper  lumbar  vertebrae,  the  disease  is  termed  lumbar  ab- 
scess.* It  may  appear  either  in  the  lumbar  region,  at  the  margin 
of  the  rectum,  or  in  the  ‘groin.  Several  vertebrae  are  found  exca- 
vated or  destroyed  by  caries.  As  in  the  other  articulations,  how- 
ever, this  disease  may  terminate  in  irregular  osseous  union  of  seve- 
ral vertebrae,  forming  a species  of  ankylosis. 

The  forms  of  disease  now  enumerated  are  chiefly  varieties  or  ef- 
fects of  the  inflammatory  process.  Those  which  yet  demand  atten- 
tion, though  dependent  in  like  manner  on  some  abnormal  action  of 
the  periosteal  or  medullary  vessels,  are  nevertheless  so  peculiar, 
that  it  is  impossible  to  refer  them  to  the  same  general  head. 

d.  Cartilaginous  union  of  the  ribs  and  other  bones.  In  September 
1828  I met  with  a singular  instance  of  malformation  in  the  ribs  of  a 
child,  to  which  I have  not  yet  heard  of  any  example  entirely  similar. 

In  the  body  of  a boy,  two  years  and  four  months  old,  I was 
struck  by  the  shape  of  the  anterior  surface  of  the  chest.  On  each 
side,  instead  of  the  usual  convex  swell  of  the  ribs,  there  was  a re- 
markable depression  extending  from  the  third  to  the  seventh  rib  in- 
clusive, commencing  about  two  inches  from  the  sternum,  and  ex- 
tending in  breadth  along  the  chest  from  one  inch  and  a half  to  two 
inches.  This  depression  consisted  in  each  of  these  ribs  presenting 
a defect  of  conformation  from  their  posterior  convexity  to  the  junc- 
tions with  the  cartilages.  At  the  former  point  each  rib  was  sud 
denly  bent  from  its  normal  curvature  to  an  angular  or  sharp  turn, 
as  if  it  had  been  broken,  and  thence  proceeded  flat,  and  in  some 
sense  straight,  to  the  cartilage,  its  union  with  which  was  marked  by 
a depression  and  a large  and  evident  knob  or  tuberosity  not  unlike 
an  articulation.  The  deformity  thus  produced  was  so  distinct,  that 
any  one  would  have  readily  pronounced  it  the  result  of  a fracture. 
But  to  this  idea,  the  circumstance  of  its  extending  through  so  many 
ribs,  and  being  found  with  the  same  uniformity  on  both  sides,  form- 
ed an  objection  of  some  weight.  To  obtain  some  light  on  the  mat- 
ter, I removed  several  of  the  ribs,  and  made  of  these  longitudinal 
and  transverse  sections.  By  this  means  the  following  facts  were 
ascertained. 

The  bony  portion  of  the  third,  fourth,  flfth,  sixth,  and  seventh 
ribs,  underwent  at  the  posterior-lateral  convexity  a sudden  change 


* Camper,  Demonst.  Anat.  lib.  ii.  cap.  1.  art  6.  Cheston’s  Pathological  Inquiries 
and  Observations,  Case  iv.  p.  128,  and  v.  p.  1.30.  Howship,  Morbid  Anatomy,  cliap. 
vii.  p.  365. 


BONE. 


479 


of  direction,  so  that  the  second  or  straight  portion  formed  with  the 
first  or  curved  a sharp  turn  sufficient  to  constitute  exactly  a right 
angle.  Longitudinal  and  transverse  sections  of  these  ribs  showed 
that  no  breach  of  continuity  had  taken  place,  and,  therefore,  that 
this  turn  was  not  the  result  of  fracture.  It  presented  a uniform, 
firm  surface,  ash-gray  in  colour,  and  traversed,  as  usual,  by  minute 
red  lines,  yet  without  manifest  trace  of  interrupted  continuity.  F rom 
this  rectangular  bend  the  substance  of  the  bone  was  of  the  usual 
appearance,  but  looser  and  more  cancellated  as  it  approached  the 
sternal  extremity,  which  was  large,  soft,  and  very  sectile.  It  was 
also  forced  inward  from  the  cartilage,  so  as  to  form  the  remarkable 
depression  observed  on  the  exterior  of  the  chest,  while  the  cartilage 
itself  projected  in  the  shape  of  a large  round  tubercle  or  eminence. 
Nothing  like  false  joint  was  observed  either  at  the  point  of  curva- 
ture or  at  the  cartilages.* 

These  appearances  were  observed  in  the  third,  fourth,  fifth,  sixth, 
and  seventh  ribs ; in  the  four  last  most  distinctly  ; in  the  third  and 
eighth  faintly,  but  still  sufficiently  well  to  contribute  to  the  general 
aspect  of  deformity  on  the  exterior  of  the  chest.  All  the  ribs  were 
soft  and  flexible,  and  spongy  and  sectile ; and  I cannot  convey  the 
idea  of  this  condition  more  distinctly  than  by  simply  stating  the 
fact,  that  in  removing  several  of  the  ribs  and  making  sections,  I did 
not  use  the  saw,  but  simply  cut  them  both  transversely  and  longi- 
tudinally. As  has  been  already  stated,  they  were  in  all  respects 
the  same  on  both  sides  of  the  chest. 

Connected  with  this  was  a peculiarity  in  the  bones  of  the  skull  not 
dissimilar.  Before  dividing  the  scalp  there  was  observed  a deep  lon- 
gitudinal furrow  in  the  situation  of  the  sagittal  suture  between  the 
two  parietal  bones  ; and  another  transverse  one  extending,  though 
less  deep,  on  each  side  along  the  coronal  suture,  between  the  posterior 
margin  of  the  frontal  bone  and  the  anterior  edge  of  the  parietal 
bones.  Not  only  was  the  fontanelle  incomplete  for  about  two 
inches ; but  no  attempt  had  been  made,  or  was  likely  to  be  made, 
to  unite  the  two  parietal  bones  with  each  other,  and  these  with  the 
frontal,  by  the  ordinary  process  of  dove-tail  ossification.  The  lon- 
gitudinal furrow  in  the  situation  of  the  sagittal  suture  was  so  large 
as  to  leave  an  inch  at  least  between  the  parietal  bones ; and  along 
this  space  these  bones  were  united  by  firm  fibro-ligamentous  struc- 
ture. The  coronal  suture  on  each  side  down  to  the  temporal  bone 

* Edinburgh  Medical  and  Surgical  Journal,  Vol.  XXXII.  Plate  I.  Edinburgh,  1829. 


480 


GENERAL  AND  rATIIOLOGICAL  ANATOMY. 


was  so  much  divided  in  like  manner,  that  the  transverse  furrow 
thus  formed  easily  admitted  the  introduction  of  the  tip  of  the  finger ; 
and  the  frontal  and  parietal  bones  were  also  united  by  firm  fibre- 
ligamentous  tissue.  When  this  was  inspected  attentively,  it  ap- 
peared to  consist  of  pericranium  and  dura  mater  firmly  adhering, 
and  without  the  smallest  trace  of  intermediate  bone.  This  was 
shown,  in  deed,  by  the  state  of  the  fontanelle,  at  which  the  pericranium 
adhered  so  firmly  to  the  dura  mater,  that  it  was  impossible  to  sepa- 
rate them  otherwise  than  by  the  knife.  This  double  membrane  was 
quite  fibro-cartilaginous,  and  was  so  tensely  stretched  between  the 
bones,  that  while  it  was  bound  down  in  the  centre  to  the  dura  mater, 
it  was  raised  to  the  margins  of  the  bones  on  each  side  of  the  de- 
pressed channel  or  sulcus.  Much  the  same  substance  surrounded 
the  whole  parietal  bones,  though  with  less  separation  of  the  lamb- 
doidal  and  temporo-parietal  sutures,  and  with  more  traces  of  ossi- 
fication. Yet  so  imperfect  was  this  process,  that  I removed  both 
parietal  bones  by  strong  scissors ; and  without  using  the  saw,  in- 
spected the  whole  brain  completely.  The  other  peculiarities  will 
be  understood  by  a short  sketch  of  the  appearance  of  the  right  pa- 
rietal bone. 

The  bone  is  very  thin,  and,  in  the  situation  of  the  parietal  pro- 
tuberance, translucent.  The  anterior  or  frontal  margin  presents 
no  serrated  appearance ; but  becoming  quickly  attenuated,  termi- 
nates in  fibro-ligamentous  structure,  which  was  leaden  gray  colour- 
ed, opaque,  and  very  tough,  but  which  has  dried  very  hard  and 
brittle,  and  is  translucent  and  traversed  by  red  vascular  lines.  At 
the  upper  mesial  extremity  of  this  margin,  the  bone,  instead  of  pre- 
senting the  usual  rectangular  process,  is  very  deficient,  and  termi- 
nates in  a portion  of  fibro-ligamentous  membrane,  at  least  eight' 
lines  broad.  The  inner  or  mesial  margin,  which  forms  the  sagittalj 
suture,  which  is  equally  void  of  serrated  edge,  is  completed  by  the] 
same  sort  of  texture ; but  the  posterior  margin,  corresponding  to  the' 
occipital  anterior  of  the  bone,  is  firmer,  and  presents  in  some  partsj 
points  of  ossification  ; and  one  of  these  is  what  would  afterwards  have] 
constituted  a Wormian  bone.  The  inferior  margin,  where  it  corre- 
sponds to  the  temporal  bone,  is  separated  from  that  bone  by  a thin 
portion  of  the  same  membranous  substance,  about  two  lines  broad, 
but  without  trace  of  bony  matter.  The  bone  was  soft  and  sectile, 
as  indeed  were  the  bones  of  the  skull  in  general ; and  as  a proof  of  ‘ 
this,  the  instrument  has  divided  the  scaly  portion  of  the  temporal 
bone,  and  left  it  attached  by  ligamentous  matter  to  the  parietal. 


BONE. 


481 


Though  the  sudden  rectangular  turn,  or  change  of  direction  had 
at  first  sight  the  appearance  of  a fracture  which  had  been  after- 
wards consolidated,  yet  there  was  no  reason  to  think,  from  the  his- 
tory and  circumstances  of  the  case,  that  this  injury  was  the  cause 
of  the  malformation.  The  peculiar  bad  configuration  of  these  ribs 
had  existed  from  the  moment  of  birth,  and  appeared  to  have  at- 
tracted little  attention  from  the  relatives.  It  was  found,  as  already 
stated,  on  both  sides  of  the  chest ; and  it  was  impossible,  in  making 
sections  of  several  of  the  ribs,  to  discover  any  of  those  marks,  by 
which  the  existence  of  a previous  fracture  is  recognized. 

The  state  of  the  cranial  sutures  is  less  uncommon  than  that  of 
the  ribs.  For  I believe  it  may  be  regarded  as  a variety  of  that 
malformation  which  has  been  distinguished  by  some  authors  as 
opening  of  the  sutures.  Portal  especially,  in  speaking  of  the  oc- 
currence of  this  phenomena  in  young  subjects,  remarks,  that  though 
rare,  it  is  occasionally  observed  to  the  age  of  two  or  three  years ; 
but  adds,  that  at  a more  advanced  age  it  is  uncommon  to  find  the 
sutures  separated,  in  consequence  of  the  operations  of  an  internal 
cause.* 

This  child  had  been  destroyed  by  bronchitis.  But  all  the  other 
internal  organs  were  sound. 

On  the  cause  of  this  deficiency  in  the  bones  of  the  chest  and  head 
it  is  difficult  to  ofier  even  a conjecture.  It  was  the  opinion  of  se- 
veral relatives  of  the  mother,  that  the  peculiar  misshaping  of  the 
chest  had  been  caused  by  tight  lacing  and  excessive  compression  dur- 
ing pregnancy.  To  the  operation  of  this  cause  being  adequate,  the 
chief  objection  is  the  fact,  that  it  is  difficult  to  imagine  any  degree 
of  compression  of  this  kind,  which  would  not  rather  have  caused  the 
death  of  the  child,  f 

In  1828  M.  Dupuytren  published  in  the  Repertoire  Generate 
d' Anatomie,  with  four  illustrative  cases,  an  account  of  a malforma- 
tion or  deformity  in  the  bones  of  the  chest,  not  dissimilar.  This  he 
represents  to  consist  in  a depression  more  or  less  considerable  of 
the  bones  of  the  chest,  in  proportional  prominence  of  the  sternum, 
of  the  belly  anteriorly,  and  of  the  vertebral  column  posteriorly. 
In  infants  affected  by  this  deformity,  the  sternum  projects  forward 
like  the  keel  of  a vessel ; the  spinal  column  rises  like  the  back  of  an 
ass ; and  the  ribs  are  not  only  flattened  but  depressed  towards  the 

* Anatomie  Medicate,  Tome  i.  p.  96. 

t Account  of  an  Instance  of  Malformation  in  some  of  the  Bones  of  the  Skeleton. 
By  David  Craigie,  M.  D.  Edinburgh  Medical  and  Surgical  Journal,  Vol.  XXXII.  p. 
51.  Edinburgh,  1829. 

H h 


482 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


chest,  nearly  as  if  at  the  period,  when  they  were  soft,  flexible,  and 
capable  of  taking  all  shapes  and  curvatures,  they  had  been  com- 
pressed from  one  side  to  the  other,  as  is  done  in  killing  pigeons, 
by  placing  the  fingers  beneath  the  wings  and  compressing  the  sides 
of  the  chest.  This  deformity  is  so  considerable  in  some  children 
that  it  is  possible  to  embrace  both  sides  of  the  chest  with  the  fingers 
of  the  same  hand.  The  transverse  diameter  of  the  chest  is  dimi- 
nished from  one-fourth  to  one-third,  or  even  one- half,  while  the 
antero-posterior  and  vertical  diameters  are  in  a similar  rate  increased. 

This  change  in  the  natural  figure  and  dimensions  of  the  bony 


walls  of  the  chest  exerts  great  and  hurtful  effects  on  the  functions  of 


the  contained  organs. 


Respiration  is  habitually  short  and  oppress- 
ed, with  inexpressible  anxiety  and  anguish,  and  threatening  suffo- 
cation ; the  infant  cannot  suck ; afterwards  speech  is  short,  inter- 
rupted, and  panting.  The  motions  of  the  heart  are  oppressed,  con- 
strained, and  irregular.  Sleep  is  disturbed,  noisy,  and  accompanied  1 
with  great  labour  in  breathing ; while  the  suflTerers  lie  with  the] 
mouth  open.  Their  repose  is  often  interrupted  by  frightful  dreams.i 

Of  the  anatomical  state  of  the  bones  M.  Dupuytren  says,  that] 
M.  Breschet  only  recognized  some  retardation  in  the  development] 
of  the  skeleton,  disjunction  of  the  bones  of  the  cranium  at  a period] 
at  which  these  bones  should  normally  liave  been  united,  persistence] 
of  the  epiphyses,  or  swelling  of  the  extremities  of  the  cylindrical] 
bones,  sundry  torsions  of  their  dinphyses,  and  little  consistence] 
in  their  tissue,  so  that  they  were  sectile  rather  than  fragile,  and  re- 
sembled bones  softened  by  immersion  in  weak  nitric  acid.  Denti- 
tion was  retarded;  the  teeth  of  the  first  or  second  dentition  altered] 
the  crown  eroded,  partly  destroyed,  and  furrowed  on  their  anteriorl 
surface. 

The  most  remarkable  circumstance  in  the  internal  and  soft  or-' 
gans  observed  by  Dupuytren  in  this  sort  of  deformity,  is  the  swel- 
ling of  the  tonsils,  with  which  it  is  almost  invariably  attended. 
These  glands  are  often  so  much  enlarged  as  seriously  to  impede 
respiration,  and  require  to  be  partly  or  wholly  resected.* 

The  lungs  are  depressed  towards  the  vertebral  column ; and  ge- 
nerally bear  on  their  surface  the  impression  of  the  ribs.  The 


• Memoire  sur  la  Depression  Laterale  des  Parois  de  la  Poitrine.  Par  M.  le  Baron 
Dupuytren.  Repertoire  Generale  d’Anatomie  et  de  Physiologie,  Tome  Vqmeme,  p. 
110.  Paris,  1828. 

Leqons  Orales  de  Clinique  Chirurgicale,  &c.  Tome  Imier.  Deuxieme  edition. 
Paris,  1829.  Article  ix.  p.  182. 


I 


BONE. 


483 


children  are  sometimes  affected  with  pulmonary  catarrh,  and  em- 
physema of  the  lungs. 

This  disease  may  prove  fatal  during  the  first  days  or  weeks  of 
existence;  and  if  it  do  not,  it  gradually  wears  dowm  the  sufferers  by 
certain  steps  to  extreme  emaciation  and  debility,  terminating  in 
death. 

Though  I have  mentioned  these  two  instances  of  deformity  of  the 
bones  together,  and  though  in  several  respects  they  strongly  re- 
semble each  other,  yet  I am  not  sure  that  they  are  exactly  alike. 
It  is  remarkable  that  M.  Dupuytren  says  nothing  of  any  cartilagi- 
nous union  of  the  ribs  at  the  point  of  depression, — a circumstance 
which,  if  present,  could  scarcely  have  escaped  the  notice  of  M. 
Breschet. 

On  the  other  hand,  in  the  case  detailed  by  myself,  though  the 
child  had  died  of  a bronchitic  attack,  the  tonsils  were  not  larger 
than  usual.  Again,  I see  daily  young  persons  wdth  tonsils  more 
or  less  enlarged,  some  so  much  that  1 know  the  presence  and  degree 
of  the  enlargement  by  hearing  them  speak ; yet  in  these  I see  no 
deformity  of  the  walls  of  the  thorax. 

I think  it,  nevertheless,  highly  probable  that  both  affections, 
whether  they  are  to  be  regarded  as  alike  or  different,  depend  on,  or 
are  connected  with  the  same  general  cause ; some  peculiar  state  of 
the  osseous  system,  by  which  its  ossification  at  the  normal  rate  is 
retarded. 

It  is  necessary  to  say,  that  this  congenital  depression  of  the  tho- 
racic walls  must  not  be  confounded  with  a depression  which  also 
takes  place  in  infants  and  children,  in  connection  with  chronic  pneu- 
monia, pleurisy,  empyema,  tubercles,  and  other  affections  of  the 
lungs.  The  depression  here  adverted  to  is  the  effect  of  the  great 
and  incessant  efforts  made  to  dilate  and  compress  the  lungs,  in  the 
laboured  actions  of  respiration  induced  by  morbid  states  of  the  lungs. 

5.  Rickets.  Rachitis. — This  disease,  of  which  no  distinct  trace 
is  found  in  the  writings  of  the  ancients,  or  in  those  of  the  authors 
of  the  middle  ages,  was  first  described  by  Glisson  as  appearing  in 
England  in  the  course  of  the  17th  century.  Though  still  frequent 
in  these  islands,  it  is  not  peculiar  to  them ; and  it  is  by  no  means 
unknown  in  other  countries  of  Europe.  In  the  time  of  Petit  it 
was  common  in  France.  At  present  it  appears  to  be  occasional- 
ly seen  in  Belgium  and  Holland.  Notwithstanding  the  fact  above 
mentioned,  the  disease  is  not  to  be  regarded  as  new.  Its  oc- 
currence in  infancy  only  was  the  cause  of  its  escaping  observa- 


484 


GENERAL  AND  PATHOLOGICAL  ANATOMY 


tion.  Its  influence,  however,  in  leaving  more  or  less  deformity  of 
the  skeleton  must  have  at  all  times  attracted  notice.  Deformed 
dwarfs  have  been  known  in  all  ages.  The  gibbi^  the  vari^  and  the 
valgi  of  the  Romans  must  have  been  more  or  less  rachitic  in  infancy. 
From  this  cause  the  deformity  of  Thersites  might  have  originated. 
It  is  also  to  be  remarked,  that  Fabricius  Hildanus  delineates  the 
serpentine  lateral  curvature  of  the  spine  in  a girl  of  8,  v'hose  bones 
were  soft  as  wax,*  which  could  be  produced  by  no  other  cause  save 
rickety  softness. 

When  the  disease  first  attracted  notice,  and  the  chemical  con- 
stitution of  bone  was  understood,  it  was  believed  that  rickets  con- 
sisted merely  in  the  late  deposition  of  phosphate  of  lime.  Of  this 
theory  the  defect  is  its  simplicity.  Though  the  earthy  matter  is 
doubtless  very  deficient,  this  is  not  the  sole  change  in  the  rachitic 
skeleton.  The  bone  is  light,  spongy,  and  cellular.  The  close  or 
compact  structure  is  said  to  disappear.  The  truth  is,  that  it  is  not 
yet  formed.  The  interior  of  the  bone  is  homogeneous  like  that  of 
a foetal  bone,  without  distinct  medullary  cavity,  without  cancellated 
structure,  and  without  compact  bone ; but  presenting  the  loose 
cellular  or  areolar  arrangement  observed  at  that  period  of  life. 
The  interstitial  cells  are  filled  with  brownish  jelly-like  substance,! 
which  appears  to  be  a secretion  from  the  medullary  arteries.  The 
bone  is  soft,  of  the  consistence  of  cartilage,  and  is  easily  cut  by  the 
knife.  Its  colour  is  some  shade  of  red,  but  varies  from  light  pink 
or  brown  to  an  orange  or  fawn-coloured  tint.  This  it  derives  from 
its  vessels,  which  are  numerous,  large,  and  loaded  with  dark-co- 
loured blood  deficient  in  fibrin.  The  periosteum  is  generally 
thickened,  and  occasionally  detached.  (Cheselden,  Bichat,  Bonn.) 
In  short,  the  rachitic  bone  is  the  foetal  bone  in  internal  structure, 
but  destitute  of  its  proportion  of  calcareous  matter. 

One  of  the  peculiarities  of  the  rachitic  condition  of  the  osseous 
system  is,  that  though  the  bones  present  the  characters  now  enu- 
merated during  its  continuance,  they  afterwards  acquire  equal  or 
even  greater  firmness  and  density  than  sound  bones,  by  the  depo- 
sition of  calcareous  matter.  While  this  takes  place,  the  distinction 
between  the  cancellated  and  compact  structure  begins  to  be  esta- 
blished, and  the  formation  of  medullary  canal  is  also  begun. 


* Cent.  6,  Obs.  76.  , 

+ Morel  in  Jour,  de  Med.  Paris,  1767,  V'ol.  VII.  p.  432  ; Portal  sur  ia  Nature  du 
Racliitisme,  2de  Partie,  Art.  iii.  p.  246  ; Tacconi  in  Comm.  Bonon  ; and  Stanley  in 
Med,  Chir.  Tr.  Vol.  VII.  p.  407. 


I 


BONE. 


485 


When  this  process  once  commences,  it  proceeds  much  as  in  healthy 
bone.  In  one  respect,  however,  its  completion  is  peculiar.  Instead 
of  the  compact  matter  of  the  bone  being  equally  distributed  on  each 
side  of  the  medullary  canal,  as  in  sound  bones,  it  is  more  abundant 
at  the  internal  than  the  external  side  of  the  incurvated  bone.  Thus 
if  the  femur,  as  generally  happens,  is  incurvated  outwards,  the 
greatest  deposition  of  compact  bone  is  at  the  internal  wall.  This 
deposition  may  be  so  considerable  in  bones  which  are  much  bent, 
as  to  obliterate  entirely  the  medullary  canal.*  The  restored  ra- 
chitic bone  is  said  to  contain  more  earthy  matter  than  healthy  bone. 

6.  Mollities  Ossium  ; — Malakosteon  ; — Osteo-malacia  ; — Osteo- 
sarcosis. — To  the  ancients  this  peculiar  state  of  the  osseous  system 
appears  to  have  been  as  little  known  as  rickets.  Omitting  the  un- 
certain traces  of  its  existence,  which  are  found  in  the  writings  of 
Ebn-Sina,  and  several  of  his  European  commentators,  the  first  dis- 
tinct record  of  the  malady  was  given  in  1665  by  Bauda,  who,  in 
1650,  observed  for  ten  years  the  progress  of  the  disease  in  the  case 
of  a citizen  of  Sedan  and  in  1688  by  Gabriel,  who  found 
all  the  long  bones  of  a lady  soft,  flexible,  and  converted  into  a 
reddish  flesh-like  substance,  void  of  fibres.|  Still  more  distinct 
cases  were  published  by  Saviard  in  1691,§  and  by  Courtial  and 
Lambert  in  1700.||  About  the  same  time  Valsalva  met  with  an 
instance,  which,  however,  was  published  only  in  1760  by  Morgagni, IT 
Previous  to  this,  however,  had  been  published  a case  by  Mr  S.  Be- 
van  in  1742  ;**  that  of  the  woman  Supiot,  the  details  of  whose  his- 
tory were  given  in  France  by  M.  Morand,  and  in  England  by  Mr 
Bromfield  ;|t  the  case  of  Mary  Hayes  by  Pringle  and  Gooch  ;:ft 

’ Observations  on  the  condition  of  the  Bones  in  Rickets,  &c.  By  Edward  Stanley, 
Esq.  &c.  Med.  Chirurg.  Tr.  Vol.  VII.  p.  404. 

Traite  des  Maladies  des  Os.  Par  M.  Du  Verney.  Paris,  1751.  Tome  I.  Pre- 
face V.  p.  136. 

J Eph.  Nat.  Cur.  Dec.  3,  An.  2,  Ohs.  3.  This  is  the  case  noticed  by  Gagliardi  the 
followng  year,  1689,  which  Scarpa  also  mentions  as  the  first.  The  Professor  of  Pavia 
seems  not  to  be  aware  that  the  case  did  not  belong  originally  to  Gagliardi  but  to  Ga- 
briel. The  earliest  case,  however,  appears  to  have  been  that  of  Peter  Siga  of  Sedan. 

§ Nouveau  Recueil,  Ac.  Obs.  62,  p.  274.  1702. 

II  Histoire  dePAcad.  R.  des  Sciences,  1700,  Obs.  2.  et  Relation  de  la  Maladie  de 
Bernarde  d’Armagnac,  &c.  This  young  woman,  a native  of  Thoulouse,  died  in  the 
Hospital  of  St  Jacques  de  la  Grave  on  the  19th  November  1699. 

H Epist.  Iviii.  4.  **  Phil.  Tr.  Vol.  xlii.  p.  488. 

ft  Histoire  de  la  Maladie  Singuhere,  Ac.  Par  M.  IMorand  Fils,  1752.  hlem.  de 
I’Acad.  1753.  The  particulars  of  this  case  are  published  also  in  the  Philos.  Transact, 
for  1753-1754,  Vol.  xlviii.  where  she  is  called  Queriot,  and  in  Bromfield's  Chirurgical 
Observations  and  Cases,  Vol.  ii. 

Phil.  Tr.  1753,  Vol.  xlviii.  p.  297. 


486 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


and  that  of  E.  Winckler  by  Ludwig,*  Since  that  time  cases  have 
been  published  by  Mr  IL  Thomsonf,  Acrel4  Renard,§  and  How- 
ship-ll 

From  these  and  similar  cases  it  results,  that  In  this  disease 
the  bones  gradually  lose  their  firmness  and  consistence,  become 
soft,  flexible,  and  may  even  be  broken.  The  change  is  remarked 
first  in  the  cylindrical  bones,  and  though  it  extends  to  the  others, 
it  there  continues  to  be  most  conspicuous.  It  consists  in  the  bone 
becoming  soft,  sectlle,  reddish,  and  something  like  a mass  of  flesh. 
When  any  part  remains  unchanged,  it  is  in  the  shape  of  thin  scales 
or  crusts  at  the  outer  part  of  the  diaphysis^  or  occasional  bony 
plates  like  portions  of  egg-shell  intermixed.  The  cancellated  struc- 
ture of  the  epiphysis  entirely  disappears,  and  in  its  place  is  found 
a soft  homogeneous  reddish  mass.  The  situation  of  the  marrow  is 
occupied  by  a red,  thick,  semifluid  matter  like  clotted  blood,  mixed 
with  grease  or  suet.  The  flat  bones  of  the  skull  are  generally 
equally  soft,  flesh-like,  and  sectile.  The  cancellated  structure  of 
the  diploe  is  equally  destroyed,  and  its  place  is  occupied  by  a uni- 
form soft  reddish  substance,  from  sections  of  which  bloody  serum 
exudes.  The  periosteum  is  sometimes  thickened,  but  is  often  un- 
changed. 

The  cause  of  this  change  is  quite  unknown.  The  most  ingeni- 
ous and  probable  conjecture  regarding  it  is  that  by  Howship,  who, 
from  the  necroscopic  appearances  of  a well-described  case,  infers 
that  it  is  the  effect  of  a morbid  action  of  the  capillary  arteries  upon 
the  medullary  membrane  within  the  bone ; and  that  the  disappear- 
ance of  the  latter  is  the  effect  of  absorption  exercised  by  the  morbid 
secretion.^ 

7.  Friability.  Fragility.  In  the  disease  now  described  the  bones 
may  be  broken  by  the  weight  of  the  person,  or  slight  action  of  the 
muscles ; and  perhaps  most  cases  of  spontaneous  fracture  are  re- 
ferable either  to  incipient  osteo-sarkosis,  to  nekrosis,  or  to  spina  oen^ 
tosa.  One  instance  of  this  I certainly  traced  to  incipient  nekrosis. 
Others,  perhaps,  are  more  equivocal.  Is  the  animal  matter  ab- 
sorbed ? 

8.  Interstitial  absorption. — Under  this  name  Mr  B.  BellJun.  de- 

* Haller  Disp.  Med.-Pract.  Tom.  vi.  p.  327,  Lips.  1757. 

t Med.  Obs.  and  Inquiries,  Vol-  v.  p.  259, 

4;  Dissertatio,  &c.  Upsalse,  1788. 

§ Ramollissement  Remarkable,  &c.  Mayence,  1804. 

II  Medico-Chir.  Tr.  Ed.  VoL  ii.  p.  136. 

^ Case  of  MIollities  ossium,  &c.  Med.-Chirurg.  Tr.  Edin.  Vol.  ii.  p.  13.6, 


BONE. 


487 


scribes  a peculiar  sinking  or  condensation  of  the  cancellated  texture 
of  the  neck  of  the  thigh-bone,  occurring  chiefly  in  aged  subjects.* 
The  aflfected  part  of  the  bone  is  highly  vascular.  In  the  only  in- 
stance of  this  in  my  possession,  the  head  of  the  bone  has  lost  its 
spherical  shape,  and  is  flattened  down  upon  the  neck  not  unlike  the 
pileus  of  a mushroom.  The  most  internal  part  of  its  cartilaginous 
covering  presents  a series  of  holes  passing  into  the  cancelli.  The 
neck  is  about  one-third  of  its  usual  length,  so  that  the  head  of  the 
bone  is  lower  than  the  great  trochanter.  This  change  must  have 
been  eflPected  by  the  medullary  vessels  of  the  head  and  neck  of  the 
bone. 

9.  Angiectasis. — The  arterial  system  of  bones  is  liable  to  a pe- 
culiar abnormal  development,  in  which  they  become  much  enlarged, 
and  forming  a cyst  in  the  substance  of  the  bone,  gradually  eflfect 
its  absorption.  Cases  of  this  description  I have  already  stated  were 
observed  by  Pearson  and  Scarpa.  Similar  cases  have  occurred  to 
M.  Lallemand  and  M.  Breschetf 

10.  Eburneoid,  or  Ivory-like  Induration. — This,  which  consists  in 
bone  acquiring  extraordinary  hardness,  density,  and  closeness,  is 
occasionally  seen  in  bony  tumours,  or  exostosis,  in  bones  which 
have  been  fractured,  and  sometimes  in  those  of  the  skull,  without 
evident  morbid  condition.  In  the  case  of  Petit,  however,  an  osse- 
ous tumour  as  large  as  a melon,  and  of  the  ivory  aspect  and  con- 
sistence, was  developed  in  the  temporal  bone.J 

A species  of  eburneoid  or  porcelain  degeneration  is  liable  to 
attack  the  articular  extremities  of  bones  after  synovial  rheumatism. 
An  efihsion  of  sero-albuminous  fluid  first  takes  place ; and  when 
this  undergoes  coagulation,  it  is  found  to  contain  some  earthy  mat- 
ter, which  some  have  said  is  lithate  of  soda,  and  others  cai’bonate 
of  lime.  After  some  time,  by  the  motion  of  the  articular  surfaces, 
this  deposit  undergoes  a degree  of  polish  ; and  the  more  the  articu- 
lar surfaces  are  moved,  the  smoothness  increases,  communicating 
the  aspect  of  ground-ivory,  or  porcelain.  In  some  instances,  also, 
the  cartilages  are  worn  or  removed  by  absorption,  as  the  effect  of 
the  same  disease ; and  their  place  is  in  some  degree  supplied  by 
this  eburneoid  or  porcelain-like  deposit.  The  subject  shall  be  no- 
ticed under  the  head  of  the  synovial  membranes. 

* Essay  on  Interstitial  Absorption  of  the  thigh-bone,  Ed.  1824. 

+ Repertoire  Gen.  de  Breschet,  T.  ii.  part  2d.  Paris,  1826. 

i Maladies  des  Os,  Tome  ii.  p.  292. 


488 


GENERAL  AND  PATHOLOGICAL  ANAT03IY. 


11.  Osteo-sarhoma. — Though  this  is  mentioned  as  a distinct  va- 
riety of  morbid  change,  it  is  probably  of  the  same  nature  as  exos- 
tosis. In  this  light  it  is  viewed  by  Scarpa  and  Boyer.  Upon  the 
whole,  though  I cannot  agree  with  the  former  in  accounting  it  of 
the  same  nature  as  s-pina  ventosa^  I think  the  examples  of  osteo-sar- 
koma  may  be  referred  to  the  cartilaginous  variety  either  of  perios- 
teal or  medullary  exostosis. 

12.  Encysted  Tumours,  a.  Osteo-steatoma. — The  formation  of 
steatomatous  tumours  in  the  substance  or  at  the  surface  of  bones, 
has  been  noticed  by  Kulm,*  Hundtermark,f  Herrmann,:};  Pott,§ 
Murray,!!  Sandifort,1f  Beil,**  Von  Siebold,tf  and  above  all,  by 
Palletta||  and  Weidmann.§§  The  tumour  is  generally  encysted; 
and  though  it  is  represented  by  J.  Bell  as  originating  in  the  medul- 
lary tissue,  it  seems  occasionally  to  arise  from  the  periosteum.  Its 
contents  are  not  invariably,  as  its  name  seems  to  indicate,  of  an  adi- 
pose nature.  They  vary  from  gelatinous,  oleaginous,  and  melice- 
ritious,  to  atheromatous  and  sebaceous,  irregularly  intermixed  with 
spiculcR  and  lamella  of  bone.  Their  progressive  enlargement  causes 
by  pressure  and  absorption  destruction  of  the  contiguous  bone. 
This  is  the  process  which  by  Palletta  is  termed  ossivorous. 

b.  Hcematoma  ; (Blood-cyst.) — Of  all  the  examples  of  this  dis- 
ease (abscessus  sanguineus,)  collected  by  Palletta,  one  only  I find 
originated  in  the  substance  of  a bone, — the  tibia  in  its  upper  epi- 
physis, which  was  consumed  by  carious  absorption.  (Case  22.)  In 
several,  however,  the  tumour,  though  originating  in  the  adjoining 
tissues,  had  produced  by  progressive  encroachment  the  same  effect. 

c.  Fungus  Hamatodes. — This  is  the  same  as  the  fungous  me- 
dullary exostosis  above  noticed.  Whether  it  originates  in  this 
manner,  or  from  the  contiguous  textures,  it  produces  the  same  ero- 
sive destruction  of  the  bones.  An  instance  of  this  originating  in 
the  peritonaeum  I saw  destroy  the  bones  of  the  pelvis,  and  reduce 
the  upper  half  of  the  right  osfemoris  to  a thin  net-work  of  bone, 
which  broke  asunder  a few  days  before  death. 

13.  Scirrho- Carcinoma. — Though  this  seems  never  to  originate 

* Haller,  Disp.  Mecl.-Chir.  Vol.  V.  p.  653. 
t Haller,  Disput.  Med.-Pract.  Tome  VI.  p.  349. 

5 Diss.  Inaug.  J.  G.  Herrmanni  de  Osteo-steatomate,  Lipsiae,  1767. 

§ Phil.  Trans.  No.  459.  ||  Dissert,  de  Osteo-steatomate,  Upsalae,  1780. 

^ Mus.  Anat.  I.  161.  **  Archiv.  III.  B.  453. 

tt  Sammlung  Chirurg.  Beobacht.  u.  s.  w.  II.  B.  p.  310  and  412. 

Exercitat.  Patholog.  p.  111.  §§  De  Steatomatibus,  Mogimtiae,  1817. 


BONE. 


489 


in  the  osseous  texture,  it  often  spreads  to  it  from  the  contiguous 
one.  Thus  most  surgeons  have  seen  cancer  of  the  lip  or  scirrhus 
of  the  parotid  affect  the  lower  jaw ; cancer  of  the  female  breast 
erode  the  ribs ; cancer  of  the  penis  affect  the  ossa  pubis  ;Xand  can- 
cer of  the  eye  or  eyelids,  in  both  sexes,  affect  the  frontal,  malar, 
or  superior  maxillary  bones. 

14.  Tubercular  destruction  may  occur  in  bones ; but  it  most 
frequently  originates  in  the  periosteum  or  adjoining  tissues,  and 
passes  thence  to  the  enclosed  bone,  in  which  it  produces  the  usual 
destructive  erosion.  (Palletta.) 

15.  Hydatids  of  the  social  form  were  seen  in  the  tibia  by  Cul- 
lerier.* 

16.  In  early  life  the  growth  of  the  osseous  system  may  be  sus- 
pended or  interrupted,  so  that  the  parts  of  the  skeleton  are  incom- 
plete. This  deficiency  generally  takes  place  on  the  mesial  plane, 
at  the  line  where  the  bones  of  each  side  are  approaching  to  unite 
with  each  other.  It  is  most  common  in  the  spinous  processes  of  the 
vertebrae,  in  the  bones  of  the  head,  and  those  of  the  upper  jaw  and 
palate.  In  the  spine  it  is  generally  connected  with  the  abnormal 
effusion  of  fluid  from  the  membranes  of  the  chord,  or  the  chord  it- 
self, when  it  constitutes  spina  bifida  or  cleft  spine.  The  same  de- 
ficiency I have  seen  in  the  frontal  and  nasal  bones ; and  in  hare-lip 
it  is  by  no  means  uncommon  in  those  of  the  palate  and  superior 
jaw. 

17.  Before  concluding  this  chapter,  a few  words  may  be  said  on 
the  morbid  states  incident  to  the  teeth. 

The  enamel  is  liable  to  be  worn  down  by  the  mutual  attrition  of 
the  teeth  of  the  upper  and  lower  jaw.  This  detrition,  which  has 
been  particularly  described  by  Procbaska,f  is  most  conspicuous  in 
the  crowns  of  those  of  the  lower  jaw,  which  in  some  subjects  are  so 
much  worn  down  as  to  expose  the  central  osseous  pith  of  the  tooth. 
Though  effected  chiefly  by  attrition,  it  is  much  facilitated  by  the 
use  of  acid  substances,  and  by  those  states  of  the  stomach  and  ali- 
mentary canal  which  favour  the  formation  of  acid.  Another  form 
of  the  same  destruction  may  take  place  in  the  corresponding  sides 
of  two  teeth  which  are  too  closely  implanted  together.  The  mu- 
tual pressure  exercised  during  the  process  of  mastication  appears  to 
be  the  first  cause  of  this.  After  it  is  once  established,  it  destroys 

* Cruveilhier,  Anat.  Pathol.  Vol.  I.  p.  230. 

t Observationes  Anatomicae  de  Decremento  Dentiimi  Corporis  Humani.  Apud 
Oper.uTi  Minorum.  Paitem  Ildam,  p.  355,  &c.  Viennae,  1800. 


490 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


first  the  enamel,  and  then  the  bone  of  the  tooth,  causing  caries  in 
the  latter,  which  become  blue  or  black,  and  is  gradually  excavated 
into  a hole. 

The  most  frequent  cause  of  disease  of  the  teeth,  however,  is  in- 
flammation of  their  internal  pulp.  This,  which  is  attended  by  in- 
tense pain,  by  progressively  destroying  the  membrane,  impairs  the 
nutrition  of  the  tooth,  which  becomes  carious  in  the  bony  pith, 
while  the  enamel  cracks,  and  is  cast  off  in  the  form  of  concave 
scales  or  crusts.  The  bony  part  thus  exposed  proceeds  still  more 
rapidly  to  destruction.  It  becomes  excavated,  breaks  down,  and  at 
length  is  expelled  in  fragments. 

Inflammation  of  the  membrane  of  the  alveolar  cavities  also,  by 
injuring  the  connecting  vessels,  may  cause  carious  destruction  of 
the  teeth.  But  it  is  generally  combined  with  more  or  less  affection 
of  the  pulp.  In  the  rachitic  its  destruction  causes  the  develop- 
ment of  the  teeth  to  be  checked,  rendering  the  individual  toothless. 


CHAPTER  V. 

GRISTLE,  CARTILAGE,  Cartilago^ — Tissu  Cartilagineux. 

Section  I. 

The  cartilaginous  system  or  tissue  is  found  at  least  in  three  dif- 
ferent situations  of  the  human  body  ; 1st,  on  the  articular  extremi- 
ties of  the  movable  bones ; 2d,  in  the  connecting  surfaces  or  mar- 
gins of  immovable  bones ; 3d,  in  the  parietes  of  certain  cavities, 
the  motions  or  uses  of  which  require  bodies  of  this  elastic  substance. 

The  organization  of  gristle  is  obscure  and  indistinct.  On  exa- 
mination by  the  microscope,  its  structure  is  said  to  be  uniform  and 
homogeneous,  like  firm  jelly,  without  fibres,  plates,  or  cells.  Wil- 
liam Hunter,  however,  represents  the  articular  cartilages  as  con- 
sisting of  longitudinal  and  transverse  fibres.*  Herissant  represents 
those  of  the  ribs  as  composed  of  "minute  fibres  mutually  aggregat- 
ed into  bundles  connected  by  short  slips,  and  twisted  in  a spiral 
or  serpentine  direction.!  By  Lassone,  the  articular  cartilages  are 

* Phil.  Transact.  Vol.  XLIII.  No.  470. 

+ Mem.  de  I’Acad.  Roy.  1748.  P.  355. 


GRISTLE. 


491 


said  to  consist  of  a multitude  of  minute  threads  mutually  connected 
and  placed  as  right  angles  to  the  plane  of  the  bone,  but  so  as  to  ra- 
diate from  the  centre  to  the  circumference.*  The  general  fact  of 
fibrous  structure  is  confirmed  by  Bichat,  who  says,  that  with  a little 
attention  it  is  possible  to  recognize  longitudinal  fibres,  which  are 
intersected  by  others  in  an  oblique  or  transverse  direction,  but 
without  determinate  order.  In  its  purest  form  no  blood-vessels  are 
seen  in  it,  nor  can  they  be  demonstrated  even  by  the  finest  injec- 
tions. In  the  margins  of  those  pieces  of  gristle,  however,  which  are 
attached  to  the  extremities  of  growing  bones,  blood-vessels  of  con- 
siderable size  may  often  be  seen,  even  without  the  aid  of  injec- 
tion. In  young  subjects  a net-work  of  arteries  and  veins,  which 
is  described  by  Hunter  under  the  name  of  circulus  articuli  vascu- 
losus,  may  he  demonstrated  all  round  the  margin  of  the  cartilage 
at  the  line  between  the  epiphysis  and  it.  They  terminate  so  ab- 
ruptly, however,  that  they  cannot  be  traced  into  the  substance  of 
the  latter.  The  most  certain  proofs,  however,  of  the  organic 
structure  of  this  substance  are  the  serous  exudation  which  appears 
in  the  course  of  a few  seconds  on  the  cut  surface  of  a piece  of 
cartilage  after  a clean  division  by  the  knife ; and  that  it  becomes 
yellow  during  jaundice,  and  derives  colour  from  substances  found 
in  the  blood.  Neither  absorbents  nor  nerves  have  been  found 
in  it.  The  cellular  texture  said  by  Bichat  to  form  the  mould  for 
the  proper  cartilaginous  matter  appears  to  be  imaginary. 

The  articular  cartilages  adhere  to  the  epiphyses  by  one  surface, 
whicli  consists  of  short  perpendicular  fibres  placed  parallel  to  each 
other,  and  forming  a structure  like  the  pile  of  velvet.  This  is 
easily  demonstrated  by  maceration  first  in  nitric  acid  and  then  in 
water.  The  free  or  smooth  surface  is  covered  by  a thin  fold  of  sy- 
novial membrane,  which  comes  off  in  pieces  during  maceration. 
The  existence  of  this,  though  recently  denied  by  Gordon,  was  ad- 
mitted by  William  Hunter,  and  may  be  demonstrated  either  by 
boiling,  maceration,  or  the  phenomena  of  inflammation,  under 
which  it  is  sensibly  thickened.  All  other  cartilages  are  enveloped, 
unless  where  they  are  attached  to  bones,  by  a fibrous  membrane, 
which  has  been  therefore  named  perichondrium.  The  existence  of 
this  may  be  demonstrated  by  dissection,  and  also  by  boiling,  which 
makes  it  peel  off  in  crisped  flakes. 

The  chemical  properties  of  cartilage  have  not  been  accurately 

* Mem,  de  I’Acad.  Roy.  1752.  P.  255. 


492 


GENEEAL  AND  PATHOLOGICAL  ANATOJIY. 


examined.  Boiling  shows  that  it  contains  gelatine ; but  as  a good 
deal  of  the  matter  is  undissolved,  it  must  be  concluded  also  that  it 
is  under  some  modification,  or  united  with  some  other  principle, 
perhaps  albumen.  Immersion  in  nitric  acid  or  boiling  fluids  in- 
duces crispation  ; and  it  dries  hard  and  semitransparent,  like  horn. 

Section  II. 

Cartilage  is  subject  to  inflammation,  which  in  the  chronic  form 
passes  into  ulceration  or  erosion, — an  affection  common  in  the  ar- 
ticular cartilages  of  the  thigh-bone  and  tibia. 

In  this  state  cartilage  becomes  reddish  or  vascular,  and  flaccid, 
or  soft  and  spongy,  with  a lardaceous  appearance  and  distinct  fibrous 
arrangement.  It  swells  and  acquires  a size  double  or  even  four 
times  larger  than  natural.  In  this  state  it  does  not  become  yellow, 
nor  is  dissolved  by  boiling.  This  is  most  common  in  the  hip-joint. 
(Bichat.) 

When  inflammation  continues  some  time,  it  produces  erosion. 
The  first  trace  of  this  consists  in  minute  reddish  perforations  ap- 
pearing at  the  synovial  surface  of  the  cartilage,  and  gradually  ex- 
tending and  becoming  deeper.  At  first  they  are  circular  ; but  as 
these  perforations  by  extension  coalesce,  irregular  abraded  patches 
are  produced,  which  at  length  become  so  deep  as  to  expose  the  de- 
nuded bone.  When  this  takes  place,  as  the  process  advances,  ir- 
regular excavations  are  hollowed  in  the  epiphyses,  which  then  pre- 
sent the  state  described  at  p.  477.  This  form  of  caries,  which  re- 
sembles in  some  respects  spina  ventosa,  is,  I conceive,  the  one  to 
which  Severinus  alludes,  and  to  which  he  wishes  to  restrict  the 
epithet  of  paedarihrokake.  I have  seen  it  in  adults,  however ; and 
it  is  most  frequent  in  the  knee-joint,  in  which  I have  seen  it  re- 
move every  trace  of  cartilage.  In  this  process  Hunter  represents 
the  transverse  fibres  as  giving  v'ay  first ; but  this  distinction  is  too 
refined.  The  disease  may  terminate  in  bony  ankylosis.  It  occurs 
also  in  the  hip-joint  and  in  the  elbow-joint. 

In  the  cartilages  of  the  larynx  inflammation  takes  place  either 
primarily  or  by  extension  from  the  perichondrium  or  the  mucous 
membrane  of  the  throat.  When  it  takes  place  primarily,  it  is  re- 
presented by  Mr  Porter  as  preceded  by  ossification.  When  it  takes 
place  secondarily,  it  may  occasionally  be  traced  to  ordinary  inflam- 
mation from  exposure  to  cold,  the  poison  of  syphilis,  or  the  unfa- 
vourable operation  of  mercury.  In  either  case  it  produces  a bad 


GKISTLE. 


493 


species  of  ulceration,  with  mortification  of  the  cartilages,  which  are 
soraetiuies  coughed  up  as  dead  sloughs.  This  constitutes  one  of 
the  worst  forms  of  laryngeal  consumption,  {phthisis  laryngea.*') 

In  strumous  subjects  the  cartilages  of  the  nose  are  subject  to  a 
species  of  enlargement  or  thickening,  accompanied  with  increased 
vascularity,  and  terminating  in  unfavourable  ulceration.  In  some 
instances,  tyromatous  deposition  in  the  tubercular  form  takes  place, 
and  renders  the  nostrils  tumid,  irregularly  knobbed  and  painful. 
This,  which  also  tends  to  very  bad  ulceration,  is  one  of  the  forms 
of  the  disease  described  under  the  general  name  of  Noli  me  tangere. 
That  it  originates  in  the  cartilages  I have  observed  more  than  once; 
and  its  ravages  are  seldom  stopped  till  they  are  completely  destroy- 
ed, leaving  much  deformity. 

It  has  been  supposed  that  cartilage  does  not  readily  granulate. 
But  this  must  be  a mistake,  unless  in  regard  to  the  laryngeal  and 
tracheal  cartilages  ; for  when  bones  are  removed  from  articular  ca- 
vities, granulations  have  been  known  to  rise  from  the  cartilagi- 
nous surface ; and  there  is  no  doubt  that  wounds  of  cartilaginous 
tissue  are  fi'equeutly  united  by  granulation.  All  that  fact  and  ob- 
servation permit  to  be  said  is,  that  often  they  do  not  readily  gra- 
nulate. 

Cartilage  is  also  liable  to  ossification,  as  is  seen  in  those  of  the 
larynx  and  of  the  ribs.  In  these  the  osseous  matter  is  disseminated 
in  irregular  points  and  patches.  In  diseases  of  the  hip-joint,  the 
cartilages  of  the  thigh-bone  and  acetabulum  become  not  only  bony, 
but  may  be  converted  into  a substance  similar  to  ivory.  (Bichat.) 

When  textures,  originally  cartilaginous,  have  thus  become  pe- 
netrated by  bony  or  calcareous  matter,  they  manifestly  lose  part 
of  their  vital  properties.  They  are  much  less  capable  than  for- 
merly of  resisting  the  approaches  of  disease.  They  are  more  liable 
to  inflammation.  And  they  are  prone  to  become  affected  by  mor- 
tification or  nekrosis  exactly  as  bone ; and  in  this  condition  they 
cause  as  much  irritative  suppuration  as  dead  bone.  This  disorder 
is  observed  principally  on  the  cartilages  of  the  larynx. 

A new  formation  of  cartilage  is  frequently  found  in  various  tis- 
sues, hut  especially  in  the  serous  and  synovial  membranes,  to  which 
it  is  not  uncommon  to  find  cartilaginous  bodies  attached.  Cartila- 
ginous texture  is  also  found  in  those  sarcomatous  tumours  which 
eventually  pass  into  insanable  ulceration. 

• Observations  on  the  Surgical  Pathology  of  the  Larynx  and  Trachea,  &c.  By  W. 
H.  Porter,  A.  M.,  &c.  Dublin  and  London,  1826. 


494 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


CHAPTER  VI. 

FiBRO-CARTiLAGE, — Cartilago  Fibrosa^ — Tissue  Fibro-Cartila- 
gineux^ — Chondro-Desmoid  Texture. 

Section  I. 

Intermediate  between  the  cartilaginous  and  the  fibrous  tissues, 
Bichat  ranks  that  of  the  fibro-cartilages,  which  comprehends  three 
subdivisions.  1st,  The  membranous  fibro-cartilages,  as  those  of 
the  ears,  nose,  windpipe,  eyelids,  &c. ; 2d,  The  inter-articular  fibro- 
cartilages,  as  those  found  in  the  temporo-maxillary  and  femoro- 
tibial  articulations,  the  intervertebral  substances,  and  the  cartila- 
ginous bodies  uniting  the  bones  of  the  pelvis ; 3c?,  Certain  portions 
of  the  periosteum,  in  which,  when  a tendinous  sheath  is  formed,  the 
peculiar  nature  of  the  fibrous  system  disappears,  and  is  succeeded 
by  a substance  belonging  to  the  order  of  fibro-cartilages. 

Bedard  follows  Meckel  in  rejecting  the  first  of  these  subdivisions, 
the  individuals  of  which  are  quite  similar  to  ordinary  cartilage. 
Like  it,  they  do  not  present  the  distinct  fibrous  structure,  but  are 
covered  by  perichondrium,  the  fibres  of  which  have  evidently 
caused  them  to  be  regarded  as  fibro-cartilages.  On  tins  principle 
Bedard  gives  tbe  following  view  of  the  fibro-cartilages. 

Is?,  Fibro-cartilages  free  at  both  surfaces;  those  in  the  form  of 
menisci,  which  are  placed  between  the  articular  surfaces  of  two 
bones;  {Jibro  cartilagines  inter-articulares.)  These  are  seen  in  the 
temporo-maxillary,  sterno-clavicular,and  femoro-tibial  articulations, 
and  occasionally  in  the  acromio-clavicular  and  the  ulno-carpal 
joints.  These  ligaments  are  attached  either  by  their  margins  or 
their  extremities,  and  are  enveloped  in  a thin  fold  of  synovial  mem- 
brane. 2c?,  Fibro-cartilages  attached  by  one  surface.  Of  this  de- 
scription are  those  employed  as  pulleys  or  grooves  for  the  easy 
motion  of  tendons ; for  instance  the  chondro-desraoid  eminences 
attached  to  the  margin  of  the  glenoid  cavity  for  the  long  head  of 
the  biceps,  and  at  the  sinuosity  of  the  ischium  for  the  tendons  of  the 
obturatores.  3d,  Fibro-cartilages,  which  establish  a connection  be- 
tween bones  susceptible  of  little  individual  motion,  as  the  interver- 
tebral bodies ; or  which  unite  bones  intended  to  remain  fixed,  unless 


FIBRO-CARTILAGE. 


495 


under  very  peculiar  circumstances,  as  those  which  form  the  junction 
of  the  pelvic  bones.  (Symphysis  puhis^  sacro-iliaa  synchondrosis.') 

The  peculiarities  of  these  substances  consist  in  their  partaking 
in  different  proportions  of  the  nature  of  cartilage  and  white  fibrous 
tissue,  and,  consequently,  in  possessing  the  toughness  and  resist- 
ance of  the  latter  with  the  flexibility  and  elasticity  of  the  former. 
The  structure  of  the  fibro-cartilaginous  tissue  is  easily  seen  in  the 
intervertebral  bodies,  or  in  the  cartilages  uniting  the  pelvic  bones. 
In  the  former,  white  concentric  layers,  consisting  of  circular  fibres 
placed  in  juxta-position,  constitute  the  outer  part ; while  the  inte- 
rior contains  a semifluid  jelly.  The  concentric  fibrous  layers  are 
cartilage  in  a fibrous  shape.  In  the  latter  situation,  the  fibrous 
structure  is  equally  distinct ; while  the  cartilaginous  consistence 
shows  the  connection  with  that  organic  substance.  A similar  ar- 
rangement is  remarked  in  the  interarticular  cartilage  of  the  temporo- 
maxillary  articulation,  and  in  the  semilunar  cartilages  of  the  knee- 
joint.  In  all,  the  fibrous  is  said  to  predominate  over  the  cartila- 
ginous structure.  Their  physical  properties  are  distensibility  with 
elasticity.  Though  they  are  at  all  times  subjected  to  considerable 
pressure,  they  speedily  recover  their  former  size.  Their  chemical 
composition  appears  to  be  entirely  unknown. 

Section  II. 

There  is  little  doubt  that  the  fibro-cartilages  are  liable  to  inflam- 
mation, either  originally  commencing  in  their  own  substance,  or 
communicated  to  them  from  contiguous  parts,  especially  synovial 
membrane,  with  which  many  of  them  are  invested.  Suppuration 
of  that  which  forms  the  symphysis  pubis  was  seen  by  a friend  of 
Hunter,*  and  by  Ludovici,  in  the  person  of  a puerperal  female. 
This  was  the  effect  of  excessive  stretching  during  labour.  In  other 
instances  they  are  torn  asunder,  so  as  to  cause  diastasis  without 
suppuration.  In  one  instance,  separation  of  this  kind  appears  to 
have  been  congenital.  Palletta  and  Brodie  have  described  a va- 
riety of  vertebral  disease  which  always  commences  with,  and  some- 
times consists  in  erosion  of  the  intervertebral  cartilages ; and  most 
surgeons  have  seen  the  semilunar  cartilages  of  the  knee-joint  in- 
flamed and  eroded.  The  intervertebral  fibro-cartilages  have  been 
found  softened,  swollen,  and  distended  with  fluid.  Ossification  is 
not  uncommon,  and  in  those  of  the  sacro-iliac  and  pubal  junctions 
* Med.  Obs.  and  Inquiries,  VoL  IL 


496 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


{symphyses),  is  remarked  in  adults,  or  those  advanced  in  life  so 
frequently,  that  it  cannot  be  regarded  as  disease.  In  the  vertebrae 
it  is  also  observed,  though  less  frequently.  It  has  been  seen  most 
generally  in  the  dorsal  and  lumbar  vertebrae,  which  are  thirs  indis- 
solubly ankylosed. 

The  accidental,  or  new  development  of  the  chon dro- desmoid 
tissue,  is  not  uncommon  ; and  its  appearance  constitutes  the  ana- 
tomical character  of  the  most  usual  form  of  scirrho-carcinoma.  In 
this  state  irregular  or  amorphous  masses  of  fibro-cartilage  are  de- 
veloped in  isolated  points  of  the  organs ; and  by  their  coalescence 
progressively  invade  or  destroy  the  original  texture  of  the  part. 
In  some  instances,  a mass  of  cartilage  is  traversed  irregularly  by 
intersecting  white  or  yellow  fibrous  bands.  In  others,  irregular 
nodules  of  cartilage  are  separated  by  ligamentous  partitions.  This 
deposition,  which  ever  manifests  a tendency  to  fatal  disorganization, 
is  most  frequent  in  the  female  breast,  in  the  womb,  in  the  lacrymal 
and  parotid  glands,  and  in  the  intestinal  canal  of  both  sexes.  In 
its  progress  to  ulceration,  cavities  are  formed  containing  brownish 
jelly-like  fluid  ; and  as  it  approaches  the  surface,  fungous  growths 
and  hemorrhage  are  frequent. 


BOOK  IV. 


MEMBRANOUS,  ENCLOSING,  OR  INVESTING 
TISSUES. 


The  organic  substances,  which  have  been  already  described, 
consist  either  of  those  which  are  ramified  or  distributed  extensively 
through  the  animal  body,  or  of  those  which  are  confined  to  definite 
situations.  Those  which  are  now  to  be  examined,  are  extended 
continuously  over  considerable  spaces,  and  tissues  or  organs  very 
different  sometimes  from  each  other.  They  are  envelopes  or  mem  - 
branes^ and  consist  of  skin,  mucous  membrane,  serous  membrane, 
synovial  membrane,  and  compound  membrane. 


CHAPTER  I. 

Section  I, 

SKIN,  Cutis,  Pellis, CUTANEOUS  TISSUE. DERMAL  TISSUE. La 

Peau,  Tissu  Dermoide. — die  haut  ; das  fell,  fell,  old  Eng- 
lish. WITH  ITS  appendages,  SCARF-SKIN  OR  CUTICLE,  NAIL, 
HAIR.  EPiDERivns;  cuTicuLA.  UNGUES.  PILL — Tissu  Epider- 
moide  et  Tissu  Pileux, 

Skin  has  been  said  to  consist  of  three  parts,  true  skin,  (cutis 
vera,)  mucous  net,  (rete  mucosum,')  and  scarf-skin,  or  cuticle. 
Haller,  Camper,  and  Blumenbach  are  inclined  to  deny  the  exist- 
ence of  the  mucous  net  in  the  skin  of  the  white,  and  to  admit  it  in 
that  of  the  negro  only ; and,  in  point  of  fact,  indeed,  its  existence 
has  been  demonstrated  in  the  negro  race  only,  and  inferred  by 
analogy  to  exist  in  the  white.  “ When  a blister  has  been  applied 
to  the  skin  of  a negro,”  says  Cruikshank,  if  it  has  not  been  very 
stimulating,  in  twelve  hours  after,  a thin  transparent  grayish  mem- 
brane is  raised,  under  which  we  find  a fluid.  This  membrane  is 


498 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  cuticle  or  scarf-skin.  When  this  with  the  fluid  is  removed,  the 
surface  under  these  appears  black;  but  if  the  blister  had  been  very 
stimulating,  another  membrane,  in  which  this  black  colour  resides, 
would  also  have  been  raised  with  the  cuticle.  This  is  rete  mucosum, 
which  is  itself  double,  consisting  of  another  gray  transparent  mem- 
brane, and  of  a black  web  very  much  resembling  the  -pigmentum 
nigrum  of  the  eye.  When  this  membrane  is  removed,  the  surface 
of  the  true  skin,  as  has  been  hitherto  believed,  comes  in  view,  and 
is  white  like  that  of  a European.  The  rete  mucosum  gives  the  co- 
lour to  the  skin  ; is  black  in  the  negro  ; white,  brown,  or  yellow- 
ish in  the  European.”^ 

Cruikshank  distinguished  the  membranes  spread  over  the  sur- 
face of  the  true  skin  into  five,  each  of  which  he  conceived  are  cu- 
ticles or  secretions  from  the  outer  surface  of  the  skin,  undergoing 
transformation  into  cuticles. 

The  first  and  most  external  of  these  is  the  cuticle  or  epidermis, 
properly  so  named,  that  is  the  completed  covering  investing  the 
whole,  and  which  is  semitransparent.  This  is  constantly  rubbed 
off  or  falling  off  in  scales  ; and  its  place  is  as  constantly  supplied 
by  layers  arising  from  and  secreted  by  the  next  covering. 

This  is  the  rete  mucosum,  which  according  to  Cruikshank  is 
double,  consisting  of  an  outer  or  consistent  layer,  and  an  inner  or 
softer,  and  which  is  secreted  by  the  vascular  surface  of  the  true 
skin.  These  two  with  the  cuticle  proper  form  three  coverings. 

The  next  or  fourth  is  more  equivocal  in  existence.  It  is  a vas- 
cular membrane  spread  over  tbe  outer  surface  of  the  true  skin, 
which  becomes  most  distinct  in  various  cutaneous  inflammations, 
as  small-pox,  measles,  and  scarlet  fever.  In  this  the  small-pox 
pustules  are  situate ; and  certainly  it  seems  to  form  the  layer  in 
which  these  pustules  are  first  developed. 

Lastly,  when  a piece  of  skin  has  been  macerated,  and  this  fourth 
vascular  membrane  is  removed,  it  is  possible  to  observe  a fifth  rest- 
ing immediately  on  the  surface  of  the  true  skin. 

These  distinctions  seem  rather  minute.  The  cuticle  is  probably 
one  membrane  only  secreted  by  the  rete  mucosum  as  it  is  required  ; 
the  external  layers  being  bard  and  firm,  the  inner  soft  and  pulpy. 

The  rete  mucosum  is  evidently  a secretion  from  the  outer  vascu- 
lar surface  of  the  skin. 

With  regard  to  the  other  two  they  seem  to  be  the  external  surface 

* Experiments  on  the  Insensible  Perspiration  of  the  Human  Body,  showing  its 
affinity  to  Respiration.  By  William  Cruikshank.  London,  1795,  p.  3 and  4. 


SKIN. 


499 


of  the  true  skin  itself.  It  was,  however,  the  opinion  of  Cruikshank, 
that  these  membranes  are  not  created,  but  only  demonstrated  or 
rendered  distinct  by  eruptive  diseases  in  consequence  of  the  large 
quantity  of  blood  impelled  into  the  skin. 

Bichat  denies  the  existence  of  a mucous  coating  or  varnish  {cor- 
pus mucosum^  such  as  Malpighi  describes  it,  and  regards  the  vas- 
cular surface  of  the  corion  as  the  only  mucous  net. 

According  to  Chaussier,  the  skin  consists  of  two  parts  only,  the 
derma  {Ss^/mu)  cutis  vera  or  corion,  and  the  epidermis,  cuticle,  or 
scarf-skin  ; the  first  embracing  the  organic  elements  of  this  tissue  ; 
the  second  being  an  inorganic  substance  prepared  by  the  organic, 
and  deposited  on  its  surface.  This  opinion  is  adopted  by  Gordon, 
according  to  whom  the  skin  consists  of  two  substances  placed  above 
each  other  like  layers  or  plates  {lamincB,)  the  inner  of  which  is  the 
true  skin,  the  outer  the  cuticle  or  scarf-skin.  Bedard,  on  the  con- 
trary, thinks  that  a peculiar  matter,  which  occasions  the  colour  by 
which  the  several  races  are  distinguished,  is  found  between  the 
outer  surface  of  the  corion  and  the  cuticle ; and  that  no  fair  race 
is  destitute  of  it  except  the  albino,  the  peculiar  appearance  of  whom 
he  ascribes  to  the  absence  of  the  mucous  net  of  the  skin. 

According  to  M.  Gaultier,  the  mucous  body  of  the  negro  skin 
consists  of  four  parts ; Isf,  a series  of  minute  vascular  bundles,  to 
which  M.  Gaultier  applies  the  name  of  gemmulce  sanguinece,  and 
which  are  really  the  termination  of  vessels  ramified  on  the  papillae ; 
2d,  the  deep  whitish  layer,  consisting  of  white  vessels,  and  indicat- 
ed in  an  oblique  section  of  the  negro  skin,  by  a white  line  between 
the  surface  of  the  corion  and  a darker  undulating  line ; 3d,  the 
coloured  layer,  named  by  INI.  Gaultier  gemimdce — the  true  colour- 
ing matter  of  the  skin, — indicated  by  the  undulating  line  already 
noticed ; Ath,  the  superficial  white  layer,  consisting  of  serous  ves- 
sels as  the  first,  indicated  by  a white  line  between  the  dark  undu- 
lating line  and  the  cuticle. 

The  vascular  eminences,  {gemmulce  sanguinece)  of  M.  Gaultier, 
are  the  termination  of  the  cutaneous  papillae ; and  this  induces  1\I. 
Dutrochet  to  give  the  following  view  of  the  constituent  parts  of  the 
cutaneous  tissue.  Is?,  the  derma,  or  corion,  the  true  skin  of  the 
ancient  anatomists;  2d,  the  papillae,  or  minute  elevations  of  this 
membrane ; 3d,  the  epidermal  membrane  of  the  papillae,  which  is 
the  deep  whitish  layer  of  M.  Gaultier ; Ath,  a coloured  layer,  the 
proper  colouring  matter  of  the  skin ; 5 th,  a.  horny  layer,  which 


500 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


corresponds  to  the  superficial  whitish  layer  of  Gaultier  ; and,  Wt, 
the  epidermis,  or  cuticle. 

The  corion  of  the  human  skin,  (j)ellis,  corium^  derma,  cutis  vera) 
seems  to  consist  chiefly  of  very  small  dense  fibres,  not  unlike  those 
of  the  proper  arter  ial  coat  closely  interwoven  with  each  other,  and 
more  firmly  compacted  the  nearer  they  are  to  its  outer  or  cuticu- 
lar  surface.  The  inner  surface  of  the  corion  is  of  a gray  colour ; 
and  in  almost  all  parts  of  the  body  presents  a number  of  depres- 
sions varying  in  size  from  one-twelfth  to  one-tenth  of  an  inch,  and 
consequently  forming  spaces  or  intervals  between  them.  These 
depressions,  which  correspond  to  eminences  in  the  subjacent  adipose 
tissue,  have  been  termed  areolae.  They  are  wanting  in  the  corion 
of  the  back  of  the  hand  and  foot  only. 

The  outer  or  cuticular  surface  of  the  corion  is  quite  smooth,  of 
a pale  or  flesh-red  tinge,  and  is  much  more  vascular  than  its  inner 
surface.  It  presents,  further,  a number  of  minute  conical  emi- 
nences {^papillae,')  which,  according  to  the  recent  observations  of 
Gaultier,*  and  Dutrochet,f  are  liberally  supplied  with  blood-ves- 
sels {gemmulae  sanguinece,)  and  are  the  most  vascular  part  of  this 
membrane.  In  the  ordinary  state  of  circulation  and  temperature 
during  life  these  eminences  are  on  a level  with  the  surrounding 
corion ; but  when  the  surface  is  chilled,  this  membrane  shrinks, 
while  the  papillse  either  continue  unchanged,  or  shrink  less  propor- 
tionally, and  give  rise  to  the  appearance  described  under  the  name 
of  goose  skin  ; {cutis  anserina.)  This  surface  was  said  by  the  older 
anatomists  to  present  numerous  openings,  oriflces,  or  pores ; but 
according  to  Gordon,  if  we  trust  to  mere  observation,  no  openings 
of  this  kind  can  be  recognized,  either  by  the  eye  or  the  microscope, 
except  those  of  the  sebaceous  follicles.  The  hairs,  indeed,  are 
found  to  issue  from  holes  in  the  corion,  but  they  fill  them  up  com- 
pletely. 

In  certain  situations,  for  instance  at  the  entrance  of  the  external 
auditory  hole,  at  the  tip  of  the  nose,  on  the  margins  of  the  eyelids, 
in  the  arm-pits,  at  the  nipple,  at  the  skin  of  the  pubes,  round  the 
anus,  and  the  female  pudendum,  are  placed  minute  orifices,  from 
which  exudes  an  oleaginous  fluid,  which  is  quickly  indurated.  These 
openings  lead  into  small  sacs  or  cavities  called  follicles,  (J'olliculi,) 

* Rechei'ches  sur  I’org.  de  la  peau,  &c.  Paris,  1809  and  1811. 

f Observations  sur  la  structure,  &c.  Journal  de  Phys.  Mai  1819,  and  Observations 
sxu'  la  structure  de  la  peau,  Jour.  Compl.  Vol.  V. 


SKIN. 


501 


or  sebaceous  glands,  {glandules  sebacea.')  Of  these  sacs  the  struc- 
ture is  simple.  They  appear  to  consist  simply  of  hollow  surfaces 
secreting  an  oleaginous  fluid,  which  is  progressively  propelled  to 
the  orifice,  where  it  soon  undergoes  that  partial  inspissation  which 
gives  it  the  sebaceous  or  suet-like  aspect  and  consistence.  In  the 
negro  races  the  secretion  exhales  a peculiar  strong  odour  ; and  in 
the  fair  or  red-haired  European  races  the  odour  is  also  strong. 

The  corion  is  liberally  supplied  with  blood-vessels,  nerves,  and 
absorbents.  After  a successful  injection,  its  outer  surface  appears 
to  consist  of  a uniform  net-work  of  minute  vessels,  subdivided  to  an 
infinite  degree  of  delicacy,  and  containing  during  life  blood  coloured 
and  colourless.  It  can  scarcely  be  doubted  that  this  vascular  net- 
work {rete  vasculosum)  is  the  only  texture  corresponding  to  the 
reticular  body  of  the  older  anatomists. 

It  is  well  known  that  this  membrane  when  boiled  sufficiently  long 
is  converted  into  a viscid  glutinous  liquor,  which  consists  chiefly  of 
gelatin,  (Chaptal,  Seguin,  Hatchett,  Vauquelin,  &c.)  and  that  glue 
is  obtained  in  great  quantity  from  it  for  the  purposes  of  art.  As, 
however,  in  these  operations  a portion  of  matter  is  left  undissolved, 
and  as  glue  is  completely  soluble  in  water,  while  skin  resists  it  for 
an  indefinite  time,  it  may  be  concluded,  that  though  the  chief  con- 
stituent of  the  corion  is  gelatin,  it  is  under  some  peculiar  modifi- 
cation not  perfectly  understood.  The  union  of  this  organized 
gelatin  with  the  vegetable  principle  denominated  tannin  forms 
leather,  which  is  quite  insoluble  in  water. 

Cuticle  or  scarf-skin,  {epidermis,  cuticula'),  is  a semitransparent, 
or  rather  translucent  layer  of  thin  light-coloured  matter,  extended 
continuously  over  the  outer  surface  of  the  corion.  Its  thickness  varies, 
being  thinnest  on  those  parts  least  exposed  to  pressure  and  fric- 
tion, but  thickest  in  the  palms  and  soles.  It  is  destitute  of  blood- 
vessels, nerves,  and  absorbents ; and  there  is  reason  to  believe,  from 
observing  the  phenomena  and  process  of  its  reproduction,  that  it  is 
originally  secreted  in  the  form  of  a semifluid  viscid  matter  by  the 
outer  surface  of  the  corion  ; and  that,  as  it  is  successively  worn  or 
removed  by  attrition,  it  is  in  like  manner  repaired  by  a constant 
process  of  secretion  or  deposition.  This  semifluid  viscid  matter, 
which,  in  point  of  fact,  is  found  between  the  outer  surface  of  the 
corion  and  the  firm  cuticle,  appears  to  be  the  substance  men- 
tioned by  Malpighi,  and  so  often  spoken  of  as  the  mucous  body 
or  net ; {corpus  mucosum,)  It  is  certainly  quite  inorganic ; and  it 


502 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


is  impossible  to  explain  its  production  otherwise  than  by  ascribing 
it  to  the  outer  or  vascular  surface  of  the  corion. 

Cuticle  is  rendered  yellow,  and  finally  dissolved  by  immersion  in 
nitric  acid.  It  is  also  dissolved  by  sulphuric  acid,  in  the  form  of  a 
deep  brow'n  pulp.  These,  and  some  other  experiments  performed 
by  Hatchett,  appear  to  show  that  it  consists  chiefly  of  albuminous 
matter  somehow  modified. 

This  description  shows,  that,  if  strict  observation  be  trusted,  the 
mucous  net  has  no  existence,  at  least  in  the  European.  In  the 
Negro,  Caffre,  and  Malay,  however,  a black  membrane  is  said  to 
be  interposed  between  the  corion  and  cuticle,  and  to  be  the  cause 
of  the  dark  complexion  of  these  races.  On  this  subject  I refer  to 
the  description  given  by  Cruikshank,*  v/hich  is  the  best,  the  Essay 
of  M.  Gaultier  already  quoted,  and  the  observations  of  Bedard. 
What  is  found  in  the  skin  of  the  mixed  or  half  cast  races,  i.  e,  the 
offspring  of  an  African  and  European,  or  of  a mulatto  and  Euro- 
pean ? and  how  is  the  transition  between  this  colouring  layer  and 
its  insensible  diminution  effected  ? 

Nail  is  a substance  very  familiarly  known.  On  its  nature  and 
structure  we  find  many  conjectures,  but  few  or  no  facts  in  the  writ- 
ings of  anatomists ; and  almost  all  that  has  been  written  is  the  re- 
sult of  analogical  inference,  rather  than  of  direct  observation.  It  is 
known  that  the  nails  drop  off  with  the  scarf-skin  in  the  dead  body  ; 
that  they  are  destroyed  or  diseased  by  causes  which  act  on  the 
outer  surface  of  the  corion,  and  produce  disease  of  the  cuticle  ; and 
that,  if  forcibly  torn  out,  the  surface  of  the  corion  to  which  they 
were  attached,  bleeds  profusely  and  inflames.  In  other  respects 
they  are  quite  inorganic ; but  these  facts  appear  to  warrant  the  con- 
clusion, that  the  root  of  the  nail  is  connected  with  the  organic  sub- 
stance of  the  corion,  and  that  the  whole  substance  is  the  result  of 
a process  of  secretion  quite  similar  to  that  by  which  the  cuticle  is 
formed. 

According  to  the  experiments  of  Hatchett,  they  consist  of  a sub- 
stance which  possesses  the  properties  of  coagulated  albumen,  with  a 
very  small  trace  of  phosphate  of  lime. 

The  root  of  a hair  is  not  only  that  part  which  is  contained  in  the 
bulb,  but  the  portion  which  is  lodged  in  the  skin.  The  middle  part 
and  the  point  are  those  which  project  beyond  the  surface  of  the  skin. 
The  hull)  is  a small  sac  fixed  in  the  inner  surface  of  the  corion,  in 

* Experiments,  &c.  p.  31. 


SKIN. 


503 


the  contiguous  filamentous  tissue,  and  receiving  the  extremity  or 
root  of  the  hair  implanted  in  it. 

Every  hair  is  cylindrical,  tapering  regulaidy  from  the  root  to  the 
point,  and  solid,  but  containing  its  proper  colouring  matter  in  its 
substance.  The  colour  varies,  but  the  root  is  always  whitish  and 
transparent,  and  softer  than  the  rest ; the  fixed  or  adhering  part  of 
the  root  is  almost  fluid.  When  hair  is  decolorized,  it  becomes 
transparent  and  brittle,  and  presents  a peculiar  silvery-white  colour ; 
and  as  hairs  of  this  kind  are  few  or  abundant,  it  gives  the  aspect  of 
gray,  hoary,  or  white-hair. 

The  bulb,  though  visible  in  a hair  plucked  out  by  the  root,  is  too 
small  in  human  hair  to  be  minutely  examined ; and  Chirac,  Gaul- 
tier, and  Gordon,  have  therefore  described  its  structure  and  appear- 
ances from  the  bulbs  of  the  whiskers  of  large  animals,  the  seal  for 
example,  in  which  it  is  much  more  distinct.  According  to  researches 
of  this  kind,  every  bulb  forms  a sort  of  sac  or  follicle,  which  con- 
sists of  two  tunics,  an  inner  one,  tender,  vascular,  and  embracing 
closely  the  root  of  the  hair  ; and  an  outer,  which  is  firmer  and  less 
vascular,  and  surrounds  the  inner  one,  while  it  adheres  to  the  fila- 
tnentous  tissue  and  the  inner  surface  of  the  corion.  When  the  hair 
issues  from  the  bulb,  it  passes  through  an  appropriate  canal  of  the 
corion,  which  is  always  more  or  less  oblique,  but  which,  as  has  been 
already  said,  it  fills  completely  ; and  it  afterwards  passes  in  a simi- 
lar manner  through  the  scarf-skin.  Nervous  filaments  have  been 
traced  into  the  bulbs  of  the  whiskers  of  the  seal  by  Rudolph!  and 
the  younger  Andral.  The  bulb  or  follicle,  in  short,  is  inorganic, 
and  forms  by  secretion  the  inorganic  hair. 

The  structure  of  hair  itself  appears  to  be  either  so  simple,  or  so 
incapable  of  being  further  elucidated,  that  anatomists  have  not  given 
any  facts  of  consequence  regarding  it.  Its  outer  surface  is  believed 
to  be  covered  with  imbricated  scales,  because  in  moving  a single 
hair  between  the  finger  and  thumb,  it  follows  one  direction  only. 

Hair  is  believed  to  be  utterly  inorganic,  though  the  phenomena 
of  its  growth,  decoloration,  and  especially  of  the  disease  termed 
Polish  plait,  {plica  Polonica^  have  led  various  authors  to  regard  it 
as  possessed  of  some  degree  of  vitality.  These  phenomena,  how- 
ever, may  be  explained  by  the  occurrence  of  disease  in  the  bulhs  or 
generating  follicles.  Hair  is  insoluble  in  boiling  water,  but  Vau- 
quelin  succeeded  in  dissolving  it  by  the  aid  of  Papin’s  digester. 
From  the  experiments  of  this  chemist,  and  those  of  Hatchett,  it  may 


504 


GENERAL  AND  PxiTHOLOGICAL  ANATOMY. 


be  inferred  that  hair  consists  of  an  animal  matter,  which  appears  to 
he  a modification  of  albumen,  a colouring  oil,  and  some  saline 
substances.* 

Section  II. 

The  cutaneous  texture  and  appendages  are  liable  to  many  forms 
of  disease.  Most  of  them,  however,  may  be  referred  to  some  form 
of  the  inflammatory  process,  or  to  changes  in  texture  either  original 
or  acquired. 

I.  Inflammation  assumes  in  this  texture  a great  variety  of  forms, 
which  it  is  the  province  of  pathological  anatomy  to  distinguish  ac- 
curately. This  was  first  attempted  by  Cullen,  whose  phlegmon  and 
erythema  were  intended  to  designate  two  forms  of  cutaneous  in- 
flammation, according  as  the  vessels  of  the  internal  or  external  sur- 
face are  the  seat  of  morbid  action.  The  distinction,  though  judi- 
cious, was  overlooked ; and  those  who  confided  in  his  practical  in- 
structions, without  attending  to  the  correctness  of  his  pathology  or 
the  fidelity  of  his  descriptions,  transferred  the  seat  of  phlegmon  from 
the  skin,  in  which  it  was  placed  by  Cullen,  to  the  cellular  tissue, 
where  it  has  since  remained.  This  error  was  abetted  by  J.  Hunter 
and  C.  Smyth,  whose  distinctions  of  inflammation,  according  to  the 
tissues  in  which  it  occurs,  place  rose  in  the  skin,  and  phlegmon  in 
the  cellular  membrane.  These  views  were  generally  adopted  till 
the  appearance  of  Bichat,  who  attempted,  after  the  example  of 
Cullen,  to  distinguish  cutaneous  diseases  according  to  their  seat  in 
the  cutaneous  tissue.f  As  this  is  obviously  the  most  rational 
method,  and,  though  not  much  followed  by  practical  authors,  has 
received  the  approbation  of  such  observers  as  Meckel  and  Bedard, 
it  is  best  calculated  for  the  order  to  be  observed  in  the  present 
treatise. 

Cutaneous  inflammation,  though  it  eventually  affect  the  sub- 
stance, which,  however,  is  not  frequently,  may  he  conveniently  dis- 
tinguished in  the  following  manner.  First,  it  may  be  seated  in 
the  exterior  or  cuticular  surface  of  the  corion ; secondly,  it  may 
affect  the  papillae  or  minute  elevations  of  the  corion ; thirdly,  it 
may  affect  the  substance  of  the  corion ; fourthly,  it  may  occur  at 
the  inner  or  attached  surface  of  this  membrane  ; fifthly,  it  may  af- 
fect the  sebaceous  follicles  ; and  sixthly,  it  may  be  connected  with 
* Annales  de  Chimie,  1805.  Tome  LVIIL,  and  Philosoph.  Trans.  1800,  Vol.  XC. 
11.  .327,  ct  seq. 

t Anatomie  Geiierale,  Tome  IV.  p.  721. 

1 


SKIN. 


505 


the  sacs  and  bulbs  of  the  hairs.  If  these  circumstances  be  adopted  as 
the  basis  of  general  division,  subordinate  characters  may  be,^derived 
from  the  mode  in  which  the  inflammatory  process  advances,  and  from 
the  effects  which  it  produces,  in  the  following  order. 


§ I.  Diffuse  or  spreadinr/  inflammation. — I.  Cutaneous  inflammations  seated  in  the  outer 
or  cuticular  sm'face  of  the  corion,  {cutis  vera,  derma,)  and  generally  spreading  along 
it. 


Measles, 

Rubeola. 

MorbiUose  eruption. 

Morbilli. 

Rash  fever,  scarlet  fever. 

Scarlatina. 

Nettle-rash, 

Urticaria. 

Rose-rash, 

Roseola. 

Common  rash. 

Erythema. 

§ 2.  Effusive  inflammation. — II.  Cutaneous  inflammation  seated  in  the  outer  surface  of 
the  corion,  producing  a fluid  which  elevates  and  detaches  the  cuticle. 

Rose,  St  Anthony’s  fire.  Erysipelas. 

Bleb  fever,  bullose  fever,  Pemphigus,  febris' bullosa. 

Simple  blebs,  Pompholyx. 

§ 3.  Punctuate  papular  inflammation. — III.  Cutaneous  inflammations  commencing  in 
circumscribed  or  definite  points  of  the  corion,  producing  minute  eminences. 

Gum,  gown,  red  gum,  tooth  gum.  Strophulus. 

Sun-rash,  prickly  heat.  Lichen. 

Itchy  rash,  Prirrigo. 

§ 4.  Punctuate  desquamating  inflammation. — IV.  Cutaneous  inflammations  of  the  outer 
surface  of  the  corion,  more  or  less  circumscribed,  affecting  its  secreting  power,  and 
producing  exfoliation  of  the  cuticle. 

Scaly  leprosy.  Lepra. 

Scaly  tetter,  Psoriasis. 

Dandriff,  Pityriasis. 

Fish-skin  disease.  Ichthyosis. 

§ 5.  Punctuate  vesicular  inflammation. — V.  Cutaneous  inflammations  originally  affecting 
the  outer  surface  of  the  corion,  circ'rmscribed,  definite,  or  punctuate,  producing  ef- 
fusion of  fluid  first  pellucid,  afterwards  slightly  opaque,  \vith  elevation  of  cuticle, 
with  or  without  further  affection  of  the  corial  tissue. 

Miliary  rash.  Miliaria. 

Shingles,  vesicular  ringworm,  or  fret.  Herpes. 

Heat  spots,  or  red-ffet.  Eczema. 

Limpet  shell  vesicle  and  scab,  Rupia. 

Cow-pox  vesicle.  Vaccinia. 

Chicken-pox,  Varicella. 

§ 6.  Punctuate  phlegmonous  or  pustular  inflammation. — VI.  Cutaneous  inflammations 
originally  affecting  the  outer  surface  and  vascular  layer  of  the  corion,  afterwards  its 
substance,  sometimes  the  sacs  and  bulbs  of  the  hairs,  and  producing  pm’ulent  mat- 
ter more  or  less  distinct. 


Small-pox, 

Variola. 

Plague, 

Pestis. 

Malignant  pustule,  Persian  fire. 

Anthrakion. 

Itch,- 

Scabies. 

Moist  or  running  tetter. 

Impetigo. 

ScaU  or  pustular  ringworm. 

Porrigo. 

Great  pox. 

Ecthyma. 

506 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


§ 7.  Punctuate  chronic phlegmonoiis  inflammation. — VII.  Cutaneous  inflammations  ori- 
ginating in  the  substance  of  the  corion,  or  in  the  sebaceous  follicles,  sometimes  at 
the  bulbs  of  the  hair,  and  terminating  in  partial  or  imperfect  suppuration,  wth 
formation  of  scales,  crusts,  &c.  and  more  or  less  destruction  of  the  sebaceous  folli- 
cles, the  piliparous  sacs,  or  of  the  corial  tissue. 

Boil,  Phyma,  Furunculus. 

Carbuncle,  Anthrax  ; Carbunculus. 

Whelk,  Acne. 

Scalp  or  chin  whelk.  Sycosis. 

Soft  tubercle,  Alolluscum. 

Canker,  Lupus,  noli  me  tangere. 

White  scall,  Vitiligo. 

Yaws,  Framboesia,  rubula. 

Sivvens,  Sibbenia. 

§ 8.  Pu/nctuatc  phlegmono-tubercular  inflammation,  chronic. — VIII.  Cutaneous  inflam- 
mations, chronic,  attended  with  general  affection  of  the  fibro-mucous  tissues. 


Arctoic  leprosy,  Radesyge, 
Lombard^evil,  Pellagra, 

Scherlievo,  Falcadina, 

Asturian  itch  or  scab,  Mai  di  Rosa, 
Crim  evil,  Krimmische  krankheit, 
Arabian  leprosy. 

Wart, 


Lepra  Norwegica. 
Pellagra. 

Lepra  Pedemontana. 
Lepra  Asturiensis. 
Lepra  Taurica. 
Elephantiasis. 
Verruca. 


§ 1.  Cutaneous  inflammations  seated  in  the  outer  or  cuticular  sur- 
face of  the  corion,  and  generally  spreading  along  it. — Inflammation  of 
the  outer  surface  of  the  corion  may  be  diffuse  and  continuous,  as  in 
scarlet  fever,  diffuse  and  interrupted,  as  in  common  rash  {erythema^ 
nettle-rash,  and  rose-rash,  or  diffuse  and  of  determinate  figure,  as  in 
measles  and  morbilli.  The  redness  with  which  superficial  cutaneous 
inflammation  is  attended  varies.  Though  it  disappears  on  pressure, 
it  returns  immediately.  In  scarlet  fever,  though  its  tint  is  indi- 
cated by  the  name,  it  often  has  a shade  of  brown  ; in  erythema,  or 
simple  rash,  it  is  rarely  so  vivid  as  in  other  forms  of  cutaneous  in- 
flammation ; in  rose  it  has  a tinge  of  yellow.  In  measles  it  as- 
sumes the  shape  of  crescentic  or  lunular  patches.  In  simple  rash 
it  terminates  gradually  in  the  sound  skin  ; but  in  one  variety  of 
this  rash,  {erythema  marginatum^  and  in  rose,  it  is  marked  by  a 
distinctly  circumscribed  edge,  or  is  said  to  be  marginate.  The 
swelling  of  superficial  cutaneous  inflammation  is  rather  a general 
distension  than  obvious  elevation.  When  it  is  obvious  to  the  eye, 
or  felt  by  tbe  finger,  and  is  at  the  same  time  confined  to  definite 
red  patches,  these  are  named  wheals.  A familiar  instance  of  this 
occurs  in  the  effect  produced  by  the  bite  of  several  insects,  the  blow 
of  a whip,  or  the  stinging  of  nettles.  Spontaneously  it  is  seen  in 

the  disease  named  nettle  rash.  In  rose,  elevation,  extensive  and 

3 


SKIN. 


507 


continuous,  conterminous  with  the  redness,  and  like  it  bounded  by 
a distinctly  circumscribed  edge,  is  uniformly  observed. 

Superficial  cutaneous  inflammation  being  seated  in  the  extensive 
vascular  net-work,  {rete  vascidosum,  reseau  vascnlaire^')  of  the  co- 
rion,  always  destroys  to  a greater  or  less  extent  its  scarf-skin,  which 
comes  away  in  small  portions  or  scales,  sometimes  in  larger  pieces, 
while  a new  but  thinner  and  more  transparent  scarf-skin  is  formed. 
The  process  by  which  these  changes  are  effected  is  termed  desqua- 
mation, and  is  observed  in  measles,  scarlet  fever,  nettle-rash,  rose- 
rash,  common  rash,  and  rose  when  it  does  not  proceed  to  the  for- 
mation of  blebs.  As  the  process  thus  defined  forms  a good  mode 
of  distinguishing  its  varieties  when  seated  in  the  outer  or  cuticular 
corial  surface,  I adopt  it  on  the  present  occasion. 

According  to  the  definition  above  given,  it  comprehends  the  fol- 
lowing diseases  : — Measles,  rash-fever  or  scarlet  fever,  nettle-rash, 
rose-rash,  common  rash. 

This  must  be  regarded  as  the  simplest  form  of  cutaneous  inflam- 
mation. It  may  indeed  be  doubted  whether  it  can  justly  be  termed 
inflammation ; for  though  the  capillaries  of  the  cuticular  surface 
of  the  corion  are  unnaturally  distended  with  blood,  and  the  usual 
functions  of  secretion  and  perspiration  are  suspended,  it  does  not 
induce  those  consequences  which  succeed  the  inflammatory  process 
in  other  tissues,  or  even  in  the  same  tissue,  in  a state  of  unequivocal 
inflammation.  It  may,  however,  be  remarked,  that,  in  other  re- 
spects, the  phenomena  of  the  disorders  referred  to  this  head  afford 
fair  examples  of  inflammatory  action.  The  skin  is  permanently 
red,  either  continuously  or  in  patches,  or  in  spots  of  definite  figure, 
diffusely  swelled,  and  unusually  warm,  or  rather  hot  and  dry.  Its 
sensations  are  also  deranged ; for  the  parts  are  either  painful, 
smarting,  or  itching,  as  in  nettle-rash,  rose-rash,  and  common  rash, 
or  the  skin  is  generally  tense  and  sore,  as  in  measles  and  scarlet 
fever.  In  each  of  these  diseases,  also,  the  capillaries  of  the  outer 
or  cuticular  ■ surface  of  the  corion  are  inordinately  distended  with 
blood,  which  appears  to  move  very  slowly,  or  stand  entirely  mo- 
tionless in  them.  The  skin  of  a person  cut  off  during  the  progress 
of  measles  or  scarlet  fever  is  marked  by  innumerable  minute  ves- 
sels disposed  in  various  modes,  arborescent,  asteroid,  reticular,  &c. ; 
and,  in  some  instances,  minute  specks  of  blood  are  effused  on  the 
corion  or  into  its  substance.  In  scarlet  fever,  confined  chiefly  to 
the  skin,  the  outer  surface  of  the  corion  of  the  face,  neck,  and 


508 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


trunk,  is  particularly  injected ; and  towards  the  close  of  the  dis- 
ease, this  capillary  injection  is  brownish  or  purple.  The  injection 
of  the  mucous  surfaces  shall  be  noticed  afterwards.  In  nettle-rash, 
this  injection  is  in  circumscribed  patches,  and  accompanied  with 
elevation,  but  disappears  greatly  after  death.  In  erythematous  in- 
flammation I have  observed  the  cuticular  surface  of  the  corion  of  a 
scarlet  red,  and  soft  velvety  texture,  and  distinctly  traversed  by 
numerous  minute  arborescent  and  asteroid  patches,  wbicb,  however, 
become  much  paler  in  a few  days. 

§ 2.  Cutaneous  inflammations  situate  chiefly  in  the  outer  surface 
of  the  corion,  producing  sero-alhuminous  fluid,  which  elevates  the  scarf 
skin  into  pushes,  blebs,  or  blisters,  (Bullae,  Phlyctaenae,)  commencing 
in  certain  parts  of  the  corion,  but  spreading  continuously. 

The  outer  surface  of  the  corion  may  be  inflamed  in  such  a manner 
as  not  to  terminate  in  desquamation  or  resolution,  but  to  pour  forth 
a sero-albuminous  yellowish  fluid,  which  detaches  the  cuticle  and 
elevates  it  in  the  form  of  a bleb  or  blister.  This  is  very  well  seen 
in  the  instance  of  scalding  by  boiling  fluids,  on  the  application  of 
the  blistering  fly,  (il/eZoc  vesicatorius,)  or  even  in  some  cases  of  fric- 
tion to  parts  naturally  tender.  In  each  of  these  cases,  in  a short 
time  large  watery  elevations  or  bladders  appear.  The  same  pro- 
cess takes  place  spontaneously  in  rose,  in  common  blebs,  and  in  the 
bullose  or  bleb  fever.  The  form  of  these  blebs  is  not  determinate; 
nor  even  are  they  always  uniform  in  appearance.  The  action  by 
which  they  are  produced,  though  more  violent  in  degree,  is  not 
different  in  kind  from  ordinary  cutaneous  inflammation.  It  is  at- 
tended, nevertheless,  with  more  swelling  of  the  corion,  more  exqui- 
site burning  heat,  and  more  searing  or  scalding  pain,  than  the  other 
forms  of  superficial  cutaneous  inflammation.  The  fluid  secreted  by 
this  process  is  sero-albuminous.  When  the  raised  cuticle  is  divided 
a yellowish  transparent  watery  fluid  escapes ; and  when  the  cuticle 
is  detached  so  as  to  expose  the  inflamed  spot,  the  inflamed  skin  is 
found  covered  by  a quantity  of  soft,  cellular,  gelatinous  matter,  of 
a yellow-white  colour,  somewhat  tough,  and  similar  to  coagulable 
lymph.  This  substance  is  traversed  by  firm  linear  partitions,  not 
uniform  in  number  or  direction,  but  forming  interstices  from  which 
serous  fluid,  the  same  as  that  which  escaped  first,  is  discharged. 
The  coagulable  matter,  which  is  albuminous,  at  the  same  time 
contracts,  and  forming  a covering  to  the  corion,  while  the  lat- 
ter begins  to  secrete  a new  cuticle,  is  at  length  thrown  off  in  the 


SKIN. 


509 


form  of  opaque  patches.  In  the  liquid  secreted  by  the  coriou 
during  the  application  of  a blister,  and  that  contained  within  the 
vesications  produced  by  scalding,  the  same  facts  may  be  recog- 
nized. That  obtained  from  the  vesication  of  a blister  separates 
spontaneously  into  coagulable  and  fluid  portions  ; and  the  addition 
to  the  latter  of  the  smallest  portion  of  nitrate  of  silver  is  followed 
by  a copious  formation  of  opake  albuminous  matter.  These  facts 
show  that  the  new  secretion,  though  discharged  fluid,  afterwards 
separates  into  a serous  and  an  albuminous  portion,  and  is  an  im- 
perfect or  modified  coagulable  lymph ; that  both  are  the  product 
of  the  inflammatory  process ; and  that  the  latter  is  analogous  to 
that  producing  albuminous  exudation  from  serous  membranes. 
This  analogy  has  not  escaped  Bichat,  who  remarks,  that  vesications 
do  not  occur  in  the  latter,  solely  because  they  want  epidermis. 
To  this  head  belongs  the  inflammation  of  cutaneous  whitloe. 

§ 3.  Cutaneous  inflammation  commencing  in  circumscribed  or 
definite  points  of  the  outer  surface  of  the  corion,  and  producing  mi- 
nute eminences  or  pimples  (papulse,)  which  disappear  gradually  or 
terminate  in  scurf,  or  minute  exfoliations  of  the  cuticle. 

When  cutaneous  inflammation  appears  in  the  form  of  innumer- 
able minute  points,  which,  without  spreading  or  coalescing,  remain 
in  general  distinct,  it  diflFers  in  nature  from  that  which  has  been 
already  considered  as  the  spreading  or  diff’use  inflammation.  The 
simplest  form  under  which  this  is  observed  to  occur,  is  that  which 
consists  of  the  minute  pointed  elevations  named  pimples  fapulcB,) 
which  may  be  described  as  small  conical  eminences,  surrounded 
by  a red  circle,  and  sometimes  attended  with  superflcial  redness 
of  the  neighbouring  skin,  but  without  definite  figure.  They  are 
slow  in  progress,  do  not  proceed  to  suppuration,  and  after  remain- 
ing an  uncertain  time,  subside  gradually,  occasioning  a branny  or 
scurfy  exfoliation  of  the  scarf-skin,  with  which  they  are  covered. 

These  seem  to  have  been  the  circumstances  which  induced  Dr 
Willan  to  consider  pimples  as  arising  from  inflammation  of  the 
papillce  or  conical  eminences  of  the  corion.  I cannot  say  that  per- 
sonal observation  has  enabled  me  to  determine,  whether  this  is  at 
all  times  truly  the  case  or  not ; and  I therefore  will  not  positively 
deny  the  accuracy  of  the  opinion.  On  this  point,  however,  I re- 
mark,— that  I have  seen  and  daily  see  instances  of  strophulus  in 
which  the  papular  eruption  can  neither  in  form  nor  distribution  be 
traced  to  the  cutaneous  papillm;  that  the  eruption  of  lichen  in 


510 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


adults  appears  in  situations  in  which  the  papillae  are  few,  as  regu- 
larly and  abundantly  as  in  those  in  which  they  are  numerous ; and 
that  we  meet  with  local  examples  of  papular  eruption  in  which  it  is 
difficult  to  suppose  the  disease  to  be  an  affection  of  the  papillae  of 
one  region  of  the  skin  only.  For  these  reasons  it  may  be  justly 
doubted  whether  in  all  instances  papular  eruptions  consist  in  in- 
flammation of  the  papillae. 

Of  the  anatomical  characters  of  pimples,  little  is  accurately 
known.  They  are  not  diseases  necessarily  fatal ; and  when  death 
takes  place  during  their  presence,  their  distinctive  characters  are 
either  much  changed,  or  entirely  gone  before  the  anatomist  can 
inspect  them.  In  some  instances  of  strophulus  in  infants  cut  off 
by  other  diseases,  I have  seen  the  corion  rough  and  slightly  raised 
in  irregular  spots,  which  were  the  seat  of  closely-set  pimples  during 
life. 

§ 4.  Cutaneous  inflammation  of  the  outer  surface  of  the  corion,  more 
or  less  circumscribed,  affecting  its  secreting  poioer,  and  thus  produc- 
ing first,  exfoliation  of  the  scarf-skin,  aftericards  vitiated  scarf-skin. 

Though  the  scarf-skin  {cuticula,  epidermis,)  and  nails  are  inca- 
pable of  injection,  and  are  therefore  believed  to  be  inorganic,  the 
former  is  remarked  to  be  more  sensible,  when  thin  and  semitrans- 
parent, than  when  thick  and  opaque,  which  it  may  be  in  certain 
regions.  It  is  also  observed,  that  when  it  is  removed  by  a blister, 
or  the  effect  of  a scald,  the  surface  of  the  corion,  when  it  ceases 
to  discharge  the  sero-albuminous  fluid  already  noticed,  becomes 
covered  by  a thin  pellicle  of  transparent  membrane,  so  delicate,  that 
it  affords  very  little  defence  to  the  subjacent  skin.  This  same 
transparent  pellicle  is  observed  in  the  skinning  or  cicatrization,  as 
it  is  named,  of  cutaneous  wounds.  If,  under  these  circumstances, 
the  formation  of  this  pellicle  be  observed,  it  will  be  found  that  it  is 
deposited  from  the  outer  or  cuticular  surface  of  the  corion,  like  a 
secreted  substance  in  a viscid  or  semifluid  state,  and  afterwards  be- 
coming hard,  dry,  and  semitransparent.  When  the  first  and  thin- 
nest pellicle  is  formed,  the  outer  surface  of  the  corion,  which  in  the- 
healthy  state  never  suspends  its  secreting  function,  continues  to  de- 
posit more  of  the  semifluid,  viscid  matter,  which  in  like  manner, 
but  more  slowly,  becomes  Arm ; and  as  successive  depositions  con- 
tinue to  be  formed  beneath  that  last  secreted,  the  cuticle  in  its 
perfect  state  consists  of  successive  layers  of  matter  secreted  from 
the  outer  surface  of  the  corion.  It  is  not  to  be  imagined,  never- 


SKIN. 


511 


theless,  that  they  can  be  distinguished  from  each  other.  The  secret- 
ing or  depositing  power  of  the  corion  is  a process  which  is  inces- 
sant and  uninterrupted ; and  after  the  first  secreted  portions  become 
firm,  others  subjacent  undergo  in  like  manner  incessant  deposition 
and  induration. 

While  this  process  of  repair  is  going  on  at  the  surface  of  the 
corion,  a process  of  wearing  or  destruction  is  with  the  same  rapidity 
in  the  healthy  state  going  on  at  the  outer  or  exposed  surface  of  the 
cuticle.  A piece  of  black  or  blue  cloth  rubbed  gently  over  the 
skin  becomes  quickly  whitened  by  minute  portions  of  scarf-skin, 
which  ai-e  thus  detached  from  the  firmer  and  more  recent  portions. 
A black  silk  stocking  drawn  on  the  leg  for  a very  short  time,  even 
when  the  skin  has  been  carefully  washed  with  soap  and  water,  comes 
oflF  covered  with  numerous  thin  white  amorphous  scales,  which  are 
found  to  be  minute  portions  of  decayed  cuticle,  ready  to  be  thrown 
off  by  the  first  slight  friction.  In  like  manner,  the  friction  of  dress, 
of  washing,  rubbing,  &c.  tends  to  remove  the  exposed  portions  of 
cuticle.  These  several  facts  show  that  this  membrane  is  a sub- 
stance secreted  from  the  outer  surface  of  the  corion  ; that  its  pro- 
duction is  a successive  and  incessant  process;  and  that  it  undergoes 
a constant  wearing  or  detrition.  As  numerous  facts  show  that  it 
is  an  albuminous  substance  much  indurated  (Hatchett,)  so  it  would 
appear  that  when  this  induration  becomes  extreme,  as  takes  place 
in  the  exterior  portions,  their  connection  with  the  recent  and  softer 
portions  is  destroyed,  and  detachment  is  the  result.  Such  is  the 
course  of  phenomena  in  the  healthy  state. 

When  the  outer  surface  of  the  corion  becomes  inflamed  or  other- 
wise disordered,  its  secretion  is  no  longer  performed  with  the  same 
perfection  or  regularity.  The  eflTect  of  this  is  seen  in  the  vitiated  state 
of  the  scarf-skin,  which  is  no  longer  the  uniform,  continuous,  firm, 
semitransparent  membrane  observed  in  health,  but  becotnes  broken, 
thickened,  opaque,  and  divided  into  numerous  scales.  Of  the  various 
modes  in  which  this  secretion  may  be  deranged,  and  of  the  varieties 
in  cuticular  disease  to  which  it  may  give  rise,  too  little  is  known  to 
speak  with  precision  of  their  individual  forms.  But  it  may  be  con- 
sidered as  certain,  that  every  morbid  state  of  the  outer  surface  of  the 
corion  gives  rise  to  certain  unnatural  conditions  of  the  cuticle,  and 
that  every  abnormal  state  of  the  cuticle  depends  originally  on  a mor- 
bid state  of  the  cuticular  or  secreting  surface  of  the  corion.  In 
general,  this  morbid  state  consists  in  some  degree  of  inflammation. 


512 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


or  at  least  it  is  attended  with  some  degree  of  this  proeess,  though  in  1 
the  chronic  form.  In  some  instances,  this  chronic  inflammation  I 
is  obviously  the  immediate  cause  of  the  derangement  of  secretion  ; I 
but  in  other  instances,  the  disordered  secretion  continues  after  the  ^ 
inflammation  subsides.  The  former  is  observed  in  the  Greek  le-  J 
prosy  (^Lepra,)  and  the  scaly  tetter,  (^Psoriasis,)  in  both  of  which  ? 
the  formation  of  the  morbid  opaque  scales  is  preceded  and  attended  ? 
by  a red  inflamed  state  of  the  corion  taking  place  in  minute  spots.  § 
It  is  less  obvious  in  dandriff,  (^Pityriasis in  which  the  surface  of  ]; 
the  corion,  though  dry,  harsh,  and  rough,  is  not  particularly  red 
or  vascular,  and  which,  therefore,  appears  to  exemplify  the  latter  » 
statement.  The  fish-skin  eruption  (Ichthyosis,)  is  in  general  so  I 
chronic,  that  it  is  difficult  to  say,  whether  it  is  or  is  not  attended  j | 
with  any  degree  of  the  inflammatory  process ; but  when  its  com-  J 
mencement  can  be  traced,  it  is  generally  possible  to  recognize 
marks  of  inflammation  of  the  outer  surface  of  the  corion.  | 

‘ §5.  Cutaneous  hiflammatio7i  07'iginally  affecting  the  outer  surf  ace  of  ~ 
the  corion,  circumscribed,  definite,  or  punctuate,  producing  effusion  of  k 
fluid,  first  pellucid,  afterwards  slightly  opaque,  with  elevation  of ' " 
cuticle,  with  or  withoxit  further  affection  of  the  corial  tissue.  ^ 

Inflammation  may  be  developed  in  many  minute  points  of  the 
corion  simultaneously,  and,  continuing  limited  to  these  points  with- 
out spreading,  may  terminate  in  each  in  the  formation  of  a pellu-  ill 
cid  fluid,  afterwards  becoming  more  or  less  opaque.  These  may 
either  be  confined  to  the  outer  surface  of  the  corion,  without  affect- 
ing its  substance,  or  beginning  originally  at  the  surface,  may  thence 
affect  its  substance. 

a.  The  individual  points  appear  first  like  a common  rash,  with 
general  redness  of  the  skin,  sometimes  like  pimples  or  minute  ele-  I 
vations,  with  a good  deal  of  redness  surrounding  them.  After 
some  hours,  a white  pearly  point  appears  at  their  summits,  while 
the  surrounding  redness  diminishes  in  breadth,  so  as  to  form  a mere  i 
circle  or  hoop  (areola,)  which,  if  minutely  examined,  is  found  to 
consist  of  a zone  of  vessels,  circumscribing  the  inflammatory  pro-  s' 
cess,  and  forming  in  their  centre  the  fluid  which  gives  the  elevation  ’ 
the  white  appearance.  After  12,  20,  or  30  hours  more,  accor-i 
ding  to  circumstances,  the  white  pearly  appearance  extends,  as-'S 
Slimes  a tint  of  yellow,  and  is  depressed  on  the  summit,  indicating* 
the  advancement  of  the  process  of  circurascrihed  inflammation.  In® 
the  course  of  two  or  three  days,  there  is  detached  a thin  crust  or  ft 


SKIJf. 


513 


scab,  which  consists  of  the  cuticle  of  the  part  with  the  dried  fluid 
adhering  to  it.  Minute  elevations  of  this  description  have  been 
termed  vesicles  (vesiculoe)^  and  the  contained  fluid  lymph  by  Dr 
Willan.  The  fluid  thus  distinguished  is  not  the  same  as  the  coa- 
gulable  lymph  of  J.  Hunter.  It  is  nevertheless  sero-albuminous, 
and  appears  to  be  quite  similar  to  thaj:  which  is  secreted  in  the  first 
stage  of  suppuration.  The  process,  by  which  it  is  secreted,  is  con- 
fined to  the  vascular  surface  of  the  corion,  and  is  not  attended  by 
ulceration  of  that  surface  in  millet  rash,  shingles  {herpes)^  and  the 
red-fret  or  mercurial  eruption  {eczema. ) In  chicken-pox  it  is  some- 
times attended  by  ulceration  of  the  corial  surface,  sometimes  not. 

b.  In  the  other  two  forms  of  vesicular  inflammation,  though  the 
process  commences  at  the  surface  of  the  corion,  it  finally  affects  the 
substance  of  that  membrane. 

c.  In  the  limpet-shell  vesicle(/zqoza),  inflammation  of  the  punctuate 
or  circumscribed  character  commences  in  one  or  more  points  of 
the  outer  surface  of  the  corion,  and  causes  the  secretion  of  a thin 
clear  fluid,  which  first  elevates  the  cuticle  into  a broad  flat  vesicle, 
and  soon  becoming  opaque,  oozes  through  the  broken  cuticle,  and 
is  hardened  into  thin,  superficial,  but  in  general  laminated  scabs. 
These  vesicles  are  surrounded  by  a red,  hard,  and  painful  margin 
or  base,  indicating  slow  inflammation  of  the  corial  tissue. 

The  progress  of  this  form  of  cutaneous  inflammation  demon- 
strates clearly  and  satisfactorily  the  gradual  transition  of  the  morbid 
action  from  the  surface  to  the  substance  of  the  corion.  The  in- 
flammation confined  at  first  to  a small  spot  by  the  usual  zone  or 
areola,  causes  merely  sero-albuminous  secretion  and  consequent 
elevation  of  the  cuticle.  If  at  this  time  the  cuticle  be  removed 
accidentally  or  intentionally,  the  subjacent  surface  of  the  corion  is 
intensely  red,  soft,  or  velvety  and  pulpy,  elevated,  and  extremely 
tender,  while  the  surrounding  ring  or  hoop  of  skin  is  hard,  and 
equally  elevated  and  red.  From  the  softened  inner  portion  the 
secretion  of  sero-albuminous  fluid,  generally  of  a reddish  tint,  con- 
tinues ; and  the  surface  itself  begins  to  become  rough,  and  to  lose 
its  velvet  aspect.  This  indicates  incipient  ulceration,  which  pro- 
ceeds to  affect  the  substance  of  the  corion,  until  it  is  either  much 
or  wholly  destroyed,  generally  in  the  form  of  an  inverted  cone ; 
while  the  place  of  the  destroyed  skin  is  supplied  by  the  sero- 
albuminous  secretion,  which  hardens  as  it  is  formed,  and  seems 
thus  to  sink  deeper  and  deeper  into  the  skin.  In  the  meanwhile, 

K k 


514 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  surrounding  portion  of  the  skin  is  much  indurated  and  inflamed, 
and  seems  to  form  a hard  ring  in  the  skin ; and  the  whole  process 
is  attended  with  extreme  pain,  searing  heat,  and  constitutional  dis- 
tress. These  phenomena  are  most  distinctly  seen  in  the  rupiapro- 
minens  and  r.  escharotica,  and  in  a variety  of  the  eruption,  which  I 
have  witnessed  in  the  persons^of  those  who  have  been  affected  with 
the  constitutional  symptoms  of  syphilis,  and  who  have  for  this  been 
subjected  to  repeated  courses  of  mercury;  (i-upia  cacliectica.) 

This  is  an  example  of  inflammation  with  destruction  of  parts, 
either  by  ulcerative  absorption,  or  by  phagedenic  ulceration. 

d.  Cow-pox  (vaccinia,)  whether  in  the  teat  of  the  cow,  or  the  skin 
of  the  human  subject,  consists  in  local  inflammation  of  the  outer 
surface  of  the  corion,  which,  by  causing  the  secretion  of  a thin 
semitransparent  fluid,  elevates  the  cuticle  into  a vesicle.  At  the 
same  time,  the  surrounding  skin  is  red,  sore  and  hard  (areola;) 
and  the  inflammatory  process  denoted  by  these  signs  causes  suppu- 
ration of  the  corion,  with  some  destruction  of  its  substance,  or 
what  is  termed  ulceration. 

If  the  thin  fluid  secreted  by  the  vaccine  vesicle  either  in  the  teat 
of  the  cow,  or  in  the  skin  of  the  human  subject,  be  taken  before  it 
has  become  opaque  or  puriform,  and  applied  to  the  surface  of  the 
human  corion  exposed  by  scratching,  slight  incision,  or  suitable 
abrasion  of  the  cuticle,  it  is  followed  by  local  inflammation  of  the 
same  characters  as  those  of  the  original  sore  or  vesicle,  from  which 
the  morbid  fluid  is  taken.  The  vaccine  inflammation  is  naturally 
divided  into  two  stages. 

1 . About  the  second  or  third  day,  or  fi*om  fifty  to  seventy  hours, 
after  insertion  of  the  fluid,  the  point  of  skin  becomes  red  and 
slightly  raised.  This  redness  and  elevation  continue  to  increase, 
till  the  cuticle  is  gradually  elevated  about  the  fifth  or  sixth 
day  into  a flat  pearl -coloured  spot  or  vesicle,  which  is  found  to  de- 
rive its  appearance  from  the  secretion  of  thin  semitransparent  fluid, 
formed  during  the  inflammatory  process  of  the  corion.  The  figure 
of  this  spot  or  vesicle  varies  according  to  the  manner  in  which  the 
vaccine  fluid  has  been  applied  to  the  part.  If  it  is  by  a longitu- 
dinal incision  or  scratch,  as  is  commonly  done,  the  shape  of  the 
vesicle  is  oval  ; if  it  has  been  by  longitudinal  and  transverse  ones 
of  nearly  equal  size,  or  by  simple  puncture,  then  it  is  more  or  less 
regularly  circular ; and  if  the  scratches  have  been  numerous  and 
irregular  in  direction,  or  if  the  fluid  has  been  applied  irregularly, 
the  shape  of  the  vesicle  is  also  irregular.  From  its  first  appearance 


SKIN. 


515 


its  upper  surface  is  uneven,  the  margin  being  more  elevated  than 
the  centre,  and  shining,  firm,  and  distended,  so  as  to  project  slightly 
beyond  the  plane  of  its  base,  or  unaffected  cuticle.  This  appearance 
it  presents  till  the  eighth  day,  when  the  surface  is  observed  on  the 
ninth  to  be  even ; and  in  some  instances  the  centre  may  be  higher 
than  the  margin.  At  this  time,  when  the  vesicle  is  supposed  to 
be  fully  formed,  it  is  found  to  consist  of  many  minute  communicating 
cells,  in  wbicb  tbe  fluid  is  contained.  This  cellular  disposition  is 
characteristic  of  the  vaccine  vesicle ; for  it  is  found  to  occur  under 
every  variety  of  circumstances  when  the  origin  of  tbe  vesicle  is 
genuine,  and  its  progress  uninterrupted. 

2.  The  circumstance  now  remarked  may  be  regarded  as  denot- 
ing the  termination  of  the  first  and  the  commencement  of  the  second 
stage.  About  the  same  time,  the  skin  round  the  vesicle  becomes 
hard,  tense,  and  red,  so  as  to  form  a ring  or  hoop,  from  one  to  two 
lines  broad  all  round,  and  from  a quarter  of  an  inch  to  two  inches  in 
diameter,  according  to  the  size  of  the  vesicle.  This  hard  red  hoop, 
which  has  been  named  areola,  marks  an  augment  or  increase  of 
inflammation  in  the  substance  of  the  corion,  which  continues  with 
pain,  tension,  and  hardness,  in  some  instances  with  obvious  swell- 
ing of  the  contiguous  parts,  till  the  end  of  the  tenth  or  the  begin- 
ning of  the  eleventh  day.  At  the  same  time  the  fluid  of  the  vesi- 
cle becomes  opaque  and  thick  like  purulent  matter,  rendering  the 
centre  yellowish,  and  depriving  it  of  its  pearly  distended  aspect. 
On  the  eleventh  and  twelfth  days,  as  the  marginal  redness  fades, 
the  surface  of  the  vesicle  becomes  brown  in  the  centre,  and  less 
clear  on  the  margin;  the  cuticle  begins  to  be  separated;  and  the  fluid 
of  the  vesicle  gradually  thickens  into  a hard  round  scab  or  crust 
of  a reddish  or  yellow  brown  colour,  which  afterwards  becomes 
black,  dry,  and  shrivelled,  and  is  loosened,  and  drops  oflP  about  the 
twentieth  day  after  the  time  when  the  vaccine  fluid  was  first  ap- 
plied. It  leaves  a permanent  uniform  scar,  distinguished  by  mi- 
nute pits  or  depressions  corresponding  to  the  number  of  cells  of 
which  the  vesicle  consisted. 

During  the  progress  of  the  local  inflammation  some  disorder  of 
the  constitution  takes  place  generally  about  the  seventh  or  eighth 
day,  in  the  form  of  loss  of  appetite  or  sickness,  slight  thirst  and  heat, 
and  dryness  of  the  skin.  The  pulse  is  almost  never  affected.  The 
vaccine  vesicle  may  also  produce  sundry  cutaneous  inflammations, 
very  transitory,  and  of  a secondary  nature.  Of  these  the  vaccine 
rose-rash  {roseola  vaccina)  is  the  most  important  and  frequent. 


516 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


It  must  not  be  understood  that  vaccine  fluid  ■when  applied  to  the 
human  body  ever  produces  a general  eruptive  disease  like  itself 
over  the  person.  This,  indeed,  was  believed  to  be  the  case  at  first 
by  Jenner,  Pearson,  Woodville,  and  perhaps  some  others.  But 
more  correct  knowledge  of  the  history  of  the  disease  shows,  that  its 
action  is  confined  in  the  human  body  to  the  identical  spots,  to  which 
it  is  applied ; that  these,  and  these  only,  become  the  seat  of  genuine 
vaccine  inflammation  ; and,  that  whatever  eruptions  or  other  morbid 
changes  in  the  skin  succeed,  or  have  been  said  to  succeed,  the  com- 
munication of  cow-pox  to  the  human  body,  are  not  the  result  of  its 
genuine  or  proper  action.  It  is  strictly  and  truly  a local  morbid 
process. 

The  history  above  given  of  the  progress  and  characters  of  the 
vaccine  vesicle,  shows  clearly  that  the  application  of  the  vaccine 
fluid,  under  proper  conditions,  is  succeeded  by  a local  inflamma- 
tion of  the  corion,  which  observes  a definite  progress,  divisible  into 
two  stages.  In  the  first  of  these  stages,  which  may  be  termed  the 
primary  or  immediate^  the  inflammatory  process  is  confined  with 
great  accuracy  to  the  cuticular  surface  of  the  corion,  and,  diflPusing 
itself  very  uniformly  from  the  point  of  insertion  at  equal  distances 
in  every  direction,  terminates  in  effusion  of  lymph  or  sero-albumi- 
nous  fluid,  and  elevation  of  the  cuticle.  During  the  first  stage, 
which  lasts  about  seven  or  eight  days,  the  minute  cells  are  formed. 
They  appear  to  consist  in  separate  points  of  inflammation,  at  which 
the  corial  vessels  discharge,  as  in  other  examples  of  the  inflamma- 
tory process,  sero-albuminous  fluid,  which  is  soon  coagulated  in  a 
definite  form.  The  coagulated  portions  form  the  partitions  of  the 
cells,  within  which  the  fluid  part  is  contained.  The  appearance  of 
the  red  ring,  (areola),  which  takes  place  about  the  eighth  day,  indi- 
cates the  commencement  of  the  secondary  inflammation.  This  con- 
sists in  the  action  being  propagated  to  the  substance  of  the  corion, 
which  is  effected  to  some  depth  in  the  formation  of  puriform  or  pu- 
rulent matter,  and  in  destruction  of  part  of  its  tissue.  The  subse- 
quent phenomena  and  eflects  are  easily  understood. 

It  is  a remarkable  property  of  cow-pock  inflammation,  that  it 
modifies  considerably  not  only  the  variolous  inflammation,  but  that 
produced  by  itself.  The  second  application  of  the  vaccine  lymph 
in  a person  who  has  previously  undergone  this  disease,  produces  a 
smaller  vesicle  of  the  same  characters,  but  less  intensely  marked. 
If  the  application  be  made  while  the  first  is  still  in  progress,  and 
before  its  areola  has  appeared,  it  produces  a vesicle  which  runs  its 


SKIN. 


517 


course  more  rapidly  than  the  original  one,  and  terminates  nearly 
at  the  same  time  with  it.  This  constitutes  the  test-pock  or  vesicle 
of  Mr  Bryce.  ( Vaccinella. ) 

e.  Of  chicken-pox  as  a cutaneous  inflammation  sometimes  aflecting 
the  corial  substance,  I have  already  merely  spoken.  Like  instances 
of  the  punctuate  inflammation,  though  it  commences  at  the  surface 
of  the  corion  with  sero-albuminous  secretion,  it  very  often  proceeds 
to  suppuration,  and  occasionally  affects  the  corial  tissue.  This  is 
seen  in  the  lenticular  and  more  distinctly  in  the  conoidal  chicken- 
pox,  in  which  the  suppurated  points  are  marked  by  depressions. 
The  cutaneous  punctuate  inflammation  of  chicken-pox  may  be  con- 
sidered as  the  link  which  connects  the  vesicular  and  the  pustular 
eruptions. 

The  facts  now  adduced  show  that  it  is  impossible  to  draw  a dis- 
tinct line  between  the  vesicle  and  the  pustule,  as  was  attempted  by 
Willan  and  Bateman.  Looking  only  at  the  pathological  process 
by  which  they  are  developed  and  advance  to  maturity,  it  is  more 
natural  to  consider  them  as  differing  in  degree  only,  and  as  gliding 
by  imperceptible  shades  into  each  other,  than  as  always  capable  of 
being  accurately  distinguished.  What  is  a vesicle  ^yhen  first  ob- 
served, may  assume  the  appearance  of  a pustule  on  the  following 
day  ; and  the  thin  sero-albuminous  fluid,  by  which  they  have  been 
supposed  to  be  distinguished,  may  be  converted  into  purulent  mat- 
ter before  the  termination  of  the  disease.  As  the  terms,  neverthe- 
less, are  useful  as  precise  distinctions  in  nomenclature  and  descrip- 
tion, and  as  they  occasionally  may  be  traced  to  a pathological  dif- 
ference, I retain  them  in  the  present  observations. 

§ 6.  Cutaneous  injinmmation  originally  affecting  the  outer  surface 
and  vascular  layer  of  the  corion^  afterwards  its  substance,  sometimes 
the  sacs  and  bidbs  of  the  hair,  and  producing  purulent  matter  more  or 
less  perfect. 

Inflammation  of  the  minute  circumscribed  kind,  though  com- 
mencing originally  on  the  surface,  may  speedily  affect  the  sub- 
stance of  the  corion,  and  in  its  progress  may  produce  more  or  less 
loss  of  substance,  with  formation  of  purulent  matter.  The  objects 
thus  formed  are  named  pustules,  and  are  to  be  viewed  as  instances 
of  genuine  phlegmonous  or  rather  purulent  inflammation  of  the 
skin.  Practical  authors  enumerate  four  forms  under  which  this 
species  of  cutaneous  inflammation  may  take  place: — 1st,  the  psy- 
dracium;  2d,  the  achor  ; 3d,  ihe  favus  ; and,  4th,  \\\<i  phlyzacium. 
To  this  number  I add  the  phlyctidium. 


518 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


1.  The psydradum  may  be  viewed  as  the  connecting  link  between 
the  vesicle  and  pustule.  It  is  small,  often  irregularly  circumscrib- 
ed, producing  but  slight  elevation  of  the  cuticle,  and  terminating 
in  a laminated  scab.  It  is  attended  with  little  or  no  redness  of  the 
surrounding  skin  {areola)^  does  not  affect  the  corion  deeply,  and 
rarely,  almost  never,  leaves  a hollow  scar.  Several  of  them  often 
appear  together,  and  becoming  confluent  after  discharging  the 
scanty  puriform  matter  which  they  furnish,  pour  out  a thin  watery 
fluid,  which  on  drying  forms  an  irregular  incrustation. 

2.  The  achor  differs  not  much  from  the  psydracium.  It  appears 
in  the  form  of  a minute  pointed  elevation,  of  a yellow  colour,  and 
succeeded  by  a thin  brown  or  yellowish  scab.  It  contains  straw- 
coloured  matter  of  the  appearance  and  consistence  of  strained  ho- 
ney ; it  is  surrounded  with  little  inflammatory  redness,  and  seems 
to  affect  the  corion  as  little  as  the  psydracium.  In  ordinary  cir- 
cumstances it  leaves  no  scar. 

3.  The  favus  may  be  esteemed  the  next  degree  of  inflammation 
of  this  tissue.  It  is  larger  and  flatter  than  the  last-mentioned  pus- 
tule, not  pointed,  and  contains  a more  viscid  matter  than  the  achor. 
It  is  surrounded  by  a slight-red,  irregular,  marginal  ring,  indicat- 
ing a more  considerable  affection  of  the  corial  tissue.  It  is  suc- 
ceeded by  a yellow,  semitransparent,  and  sometimes  cellular  scab, 
like  honey-comb. 

4.  A form  of  pustule  referable  neither  to  these  nor  to  that  which  is 
to  follow,  I must  here  mention, — i\\Q phlyctidium  or  genuine  small- 
pox pustule.  It  consists  in  a circular  or  annular  spot  of  inflamma- 
tion of  the  corion,  encircled  by  a red  ring  or  zone,  which  is  ob- 
served to  consist  of  the  outer  corial  surface  highly  vascular  and 
elevated.  W ithin  this  suppuration  takes  place.  Though  the  phlyc- 
tidium  is  observed  spontaneously  in  the  distinct  small-pox,  it  is  al- 
so produced  artificially  by  friction  of  tartar-emetic  ointment, 

5.  HhQphlyzacium  is  the  most  perfect  example  of  the  most  violent 
degree  of  this  form  of  cutaneous  inflammation.  It  is  described  as 
a large  pustule,  raised  on  a hard  circular  base,  of  a lively  red  co- 
lour, and  succeeded  by  a thick,  hard,  dark-coloured  scab.  It  is 
generally  slow  in  progress,  and,  commencing  at  once  on  the  sur- 
face and  in  the  substance  of  the  corion,  is  attended  with  consider- 
able surrounding  inflammation  ; and  the  suppurative  process  which 
follows  is  always  accompanied  with  more  or  less  destruction  of  the 

corial  tissue.  It  often  leaves  a hollow  scar.  The  surrounding 

3 


SKIN. 


519 


redness,  hardness,  and  elevation  ; the  slow  progress  and  sometimes 
tedious  suppuration  ; and  lastly,  the  loss  of  corial  substance,  are 
the  circumstances  which  indicate  the  peculiar  seat  of  this  form  of 
cutaneous  inflammation. 

Into  the  pathological  characters  of  the  individual  pustular  in- 
flammations, the  limits  of  this  treatise  do  not  permit  me  to  enter. 
On  one  or  two  of  them,  however,  I shall  offer  a few  remarks,  which 
may  tend  to  illustrate  the  general  nature  of  cutaneous  pustular  in- 
flammation. I begin  with  small-pox  as  one  of  the  most  interest- 
insf. 

a.  From  Dorainico  Cottugni  we  learn  that  it  was  the  opinion  of 
Astruc,  that  the  poisonous  matter  of  small- pox  {venenum  variolarum) 
affects  particularly  and  exclusively  the  mucous  body  (coj'pus  muco- 
sum),  which  Malpighi  describes  between  the  skin  and  cuticle,  and 
that  it  was  the  property  of  this  poison  to  induce  in  it  the  peculiar 
variolous  inflammation.  This  opinion  appears  to  Cottugni  to  be 
correct,  because  it  is  confirmed  by  dissections  made  by  him  of  the 
incipient  and  complete  small  pox  pustule.  These  dissections,  Cot- 
tugni states,  showed  the  incipient  pustule  to  consist  of  the  raised 
cuticle  without  affection  of  the  substance  of  the  corion ; that  this 
elevation  of  the  cuticle  was  occasioned  by  the  intermediate  mucous 
body  {corpus  mucosum)  being  expanded  like  jelly,  without  separa- 
tion of  parts  or  intervening  cavity ; and  that  such  separation  and 
cavity  could  be  perceived  only  when  the  pustule  was  completed. 
Variolous  pustules,  he  then  asserts,  are  of  two  kinds,  the  umbilicate 
or  depressed^  and  the  vesicular  or  crystalline.  The  umbilicate  are 
those,  the  apex  of  which  is,  from  the  very  beginning,  flattened  or 
truncated,  and  which  are  rather  lenticular  than  conical,  as  most 
pustules,  except  the  variolous,  are.  This  shape  they  retain  until  in 
the  course  of  inflammation  they  grow  to  their  full  size,  which  may 
equal  or  exceed  that  of  a lentil  either  on  the  eighth  or  ninth  days, 
or  on  the  tenth  and  eleventh.  The  cause  of  this  depressed  figure 
is  the  navel  {umbilicus)  in  the  centre  of  the  pock,  which  is  at  first 
like  an  indistinct  point,  but  afterwards,  as  the  pock  grows,  becomes 
more  elevated,  with  a flatter  figure.  From  this  central  point  or 
navel  he  represents  all  the  actions  of  the  pock,  inflammation,  sup- 
puration, and  drying  or  scabbing  to  proceed.  F or  while  it,  as  a seat 
of  the  poison,  remains  fixed,  the  surrounding  paid,  not  of  skin,  but 
of  mucous  body,  is  raised  into  an  inflammatory  ring  or  mound, 
which  prevents  the  morbid  action  from  spreading.  In  the  conflu- 


520 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


ent  small-pox  this  provision  is  not  observed.  No  outer  swelled  or 
red  ring  is  observed,  and  the  mucous  body  of  Malpighi  is  not  in 
such  circumstances  affected  with  the  just  and  laudable  action  of  the 
disease.  These  results  he  ascribes  to  the  spongy  structure  of  the 
Malpighian  membrane,  which  swells  and  secretes  a lymphy  fluid. 
In  the  crystalline  small-pox,  the  fluid  of  which  is  almost  pellucid, 
he  asserts  that  the  mucous  body,  instead  of  being  converted  into 
good  matter,  is  filled  with  a caustic  eroding  humour,  which  seldom 
fails  to  leave  deep  scars.* 

Though  these  crystalline  poets  are  nearly  allied  to  his  second 
kind,  the  vesicular,  they  must  not  be  entirely  confounded  with  them. 
They  are  utterly  destitute  of  depression  from  their  origin,  are  quite 
similar  to  minute  blisters,  and  he  conceives  them  to  be  generated 
in  a similar  manner,  that  is,  by  the  inflammatory  action  operating 
like  a scald,  and  detaching  very  rapidly  from  the  raucous  body  the 
cuticle,  so  as  to  form  vesicles  or  vesicular  pustules.  The  purple- 
like pocks  he  explains  in  a similar  manner.  They  are  merely  ve- 
sicular elevations  of  the  cuticle,  containing  at  first  a watery  fluid, 
but  mixed  afterwards  with  blood  or  bloody  fluid  exuding  from  the 
mucous  body  or  vessels  of  the  skin.  They  are  generally  mixed 
with  petechial  spots,  the  origin  of  which  depends  on  the  same 
cause. 

In  short,  the  doctrine  of  Cottugni  is  explicitly  the  following. 
The  natural  and  ordinary  character  of  the  small-pock  is  to  pro- 
duce in  the  mucous  body  (vascular  web)  of  the  skin  a pit  or  de- 
pressed point,  which  is  soon  surrounded  with  an  elevated  circle,  in- 
dicating inflammation  of  the  corial  surface.  As  this  inflammatory 
process  proceeds  from  the  central  pit  or  navel  to  the  circumference, 
the  elevated  ring  of  mucous  or  vascular  web  is  gradually  convert- 
ed into  purulent  matter,  which  necessarily  renders  the  summit  of 
the  pock  flatter  and  more  extensive,  while  its  centre  remains  de- 
pressed. The  formation  of  purulent  matter  is  indicated,  he  says, 
by  the  appearance  of  a whitish  ring  [albidus  annulus^)  which  is  at 
first  at  tlie  vertex,  but  extends  successively  to  the  base  of  the  pock. 
In  this  course,  he  says,  it  does  not  affect  the  corion  {cutis)  if  the 
pocks  be  good  ; for  before  it  reaches  this  membrane  the  purulent 
matter  occupying  the  circumference  of  the  pock  either  by  bursting 
it  escapes,  or  by  the  itching  which  it  causes  at  length  gets  an  out- 

* Dominici  Cottunnii  Regii  Anatomes  Professoris  de  Sedibus  Variolarum  Syntag- 
ma. Vienna,  1771.  Ixxx.  paragr. 


SKIN. 


521 


let.  Meanwhile  the  site  of  the  pit  or  navel  (umbilicus,)  which  was 
previously  sunk  and  hollow,  not  only  attains  the  uniform  convexity 
of  the  rest  of  the  pustule,  which  renders  it  spherical  instead  of  len- 
ticular, but  is  raised  into  a top  or  apex,  which  first  allows  the  con- 
tained matter  to  escape.  This  hardening  forms  a crust  which 
covers  the  pustule  during  the  subsequent  process  of  drying  (persic- 
catio,)  which  now  commences ; when  this  is  completed  the  crust  or 
scab  drops  oflT,  leaving  the  skin  uninjured. 

This  is,  according  to  Cottugni,  the  natural  and  most  perfect  pro- 
cess of  variolous  suppuration,  from  which  all  others  are  more  or 
less  deviations.  Thus  the  umbilicate  pocks  may  degenerate  into 
the  gangrenous,  corruptive,  crystalline,  and  warty ; the  vesicular 
deviate  into  the  purple-like  pox  only. 

The  most  doubtful  point  of  this  account  of  the  variolous  inflam- 
mation, is  that  which  relates  to  the  disease  being  entirely  confined 
to  the  mucous  body  of  Malpighi.  The  existence  of  this  membrane 
is  very  doubtful,  and  if  it  cannot  be  demonstrated,  the  opinion  of 
small-pox  being  confined  to  it  is  obviously  inconclusive.  If  the  term 
outer  surface  or  vascular  layer  of  the  corion  be  substituted  for  mucous 
body,  the  whole  description  maybe  regarded  as  not  far  from  the  truth. 
The  depressed  pit  or  navel  of  which  Cottugni  speaks,  corresponds 
with  the  central  slough  of  John  Hunter,  to  wTich  I shall  advert  in 
its  proper  place.  At  present,  the  process  of  variolous  inflamma- 
tion, if  divested  of  hypothetical  language  and  opinions,  may  be  stat- 
ed in  the  following  terms. 

The  small-pox  eruption  consists  of  circumscribed  points  of  in- 
flammation developed  simultaneously  in  many  spots  of  the  corion. 
These  inflamed  spots  (phlyctidia),  always  commence  at  the  cuticu- 
lar  or  outer  surface,  and  in  general  penetrate  to  a depth  which  is 
greater  or  less  in  different  circumstances.  After  no  long  time, 
each  phlyctidium  is  surrounded  with  a hard  red  circle  somewhat 
raised,  which  may  be  conceived  to  indicate  the  process  of  cutaneous 
inflammation.  Hunter  would  say,  and  perhaps  did  say,  that  this 
inflammation  is  of  the  adhesive  kind,  and  arises  from  lymph  effused 
into  that  part  of  the  corion  which  is  red,  hard,  and  swelled.  I 
believe  it  cannot  be  in  every  instance  shown  that  this  hard  swelling 
depends  on  effusion  of  lymph ; and  it  may  be  doubted  whether  it 
arises  from  such  effusion  in  the  case  of  small-pox.  First,  hardness 
and  swelling  take  place  at  a period  of  the  eruption  so  early,  that 
it  appears  unreasonable  to  ascribe  them  to  effused  lymph  ; Secondly, 


522 


GENERAL  ANI)  PATHOLOGICAL  ANATOMY. 


hardness  and  swelling  accompany  every  example  of  circumscribed 
or  definite  inflammation  ; Thirdly^  it  is  not  easy  to  understand  in 
what  particular  part  the  lymph  could  be  effused,  for  the  corion  does 
not  contain  cells  or  cavities  like  the  filamentous  tissue,  but  the  outer 
surface  consists  of  a smooth  dense  membrane,  abounding  in  minute 
blood-vessels ; Fourthly^  it  is  as  easy  and  more  natural  to  think 
that  if  effusion  took  place,  it  would  do  so  into  these  minute  ves- 
sels. In  point  of  fact,  the  capillaries  of  the  corion  of  the  pustular 
redness  and  hardness  are  numerous  and  distended ; and  I believe 
that  the  truest  conclusion  is,  that  the  redness,  hardness,  and  swel- 
ling of  each  pock,  consist  in  the  unusual  distension  of  the  corial 
capillaries  with  blood. 

Pustular  inflammation  of  the  skin  naturally  terminates  in  sup- 
puration, which  may  be  either  with  or  without  destruction  of  the 
corial  tissue.  In  the  variolous  phlyctidia,  when  distinct,  destruc- 
tion of  the  skin  is  rare,  but  may  occur.  There  is  reason  to  infer 
that  it  takes  place  in  eonsequence  of  a true  process  of  ulceration. 

According  to  the  observation  of  John  Hunter,  there  is  another 
mode  in  which  destruction  of  the  corion,  and  a permanent  scar  may 
be  effected.  “ The  most  eertain  character,”  that  is  the  most  cer- 
tain pathological  character,  ‘‘  of  the  small-pox,”  says  this  writer, 
“ is  the  formation  of  a slough,  or  a part  becoming  dead  by  the  vari- 
olous inflammation,  a circumstance  which  hitherto,  I believe,  has 
not  been  taken  notice  of.  This  was  very  evident  in  the  arms  of 
those  who  were  inoculated  in  the  old  way,  where  the  wounds  were 
considerable,  and  were  dressed  every  day ; which  mode  of  treat- 
ment kept  them  from  scabbing,  by  which  means  this  process  was 
easily  observed ; but  in  tbe  present  method  of  inoculation  it  is 
hardly  observable.  The  sore  being  allowed  to  scab,  the  slough 
and  scab  unite  and  drop  off  together.  The  same  indistinctness  at- 
tends the  eruptions  on  the  skin ; and  in  those  patients  who  die  of, 
or  die  while  in  the  disease,  where  we  have  an  opportunity  of  exa- 
mining them  while  the  part  is  distinct,  this  slough  is  very  evident. 
This  slough  is  the  cause  of  the  pit  after  all  is  cicatrized ; for  it  is  a 
real  loss  of  substance  of  the  surface  of  the  cutis,  and  in  proportion 
to  this  slough  is  tbe  remaining  depression.” 

‘‘  The  chicken-pox  comes  the  nearest  in  external  appearance  to 
the  small-pox ; but  it  does  not  commonly  produce  a slough.  As 
there  is  generally  no  loss  of  substance  in  this  case,  there  can  be  no 
pit.  But  it  sometimes  happens,  although  but  rarely,  that  there  is 


SKIX. 


523 


a pit  in  consequence  of  a chicken  pock ; then  ulceration  has  taken 
place  on  the  surface  of  the  cutis,  a common  thing  in  sores.”* 

The  circumstance  of  a slough  at  the  bottom  of  each  pock  or  in- 
flamed point  has  been  particularly  insisted  on  by  Joseph  Adams,  a 
most  zealous  admirer  of  the  pathology  of  Hunter,  and  an  active 
commentator  on  his  principles.  “ We  have  before  seen,”  says 
Adams,  “ that  the  peculiar  property  of  some  morbid  poisons  is  to 
produce  death  in  a part,  whether  the  inflammation  be  violent  or 
not.  Of  this  kind  is  the  small-pox,  every  individual  pustule  of 
which  is  found  with  a slough  at  the  bottom,  which  may  be  removed 
with  ease,  after  time  has  been  allowed  for  its  separation  by  suppu- 
ration. The  progress  of  the  small-pox  is  therefore  to  form  a num- 
ber of  sloughs  under  the  skin,  (on  the  cuticular  or  outer  surface  of 
the  corion,)  and  the  danger  depends  on  the  number  formed,  and 
the  violence  which  the  constitution  suflfers  from  the  first  shock  of 
that  stimulus  which  excites  it  into  this  process.  If  the  stimulus  of 
the  small-pox  virus  is  moderate,  its  local  action  follows  by  adhe- 
sive inflammation  and  slough ; after  which,  the  parts  and  constitu- 
tion have  sustained  the  first  shock,  and  the  subsequent  process  of 
suppuration,  to  separate  the  slough,  is  accomplished  with  so  much 
ease,  that  the  constitution  is  rarely  sensible  of  any  general  incon- 
venience. But  the  face  having  sustained  the  first  shock,  the  actions 
on  that  part  began  with  the  greatest  rapidity,  and  continue  so 
throughout  their  whole  progress  ; in  consequence  of  which  the  pus 
has  a higher  tinge,  and  the  progress  of  skinning  beginning  as  soon 
as  the  slough  begins  to  separate,  this  irregularity  produces  an  in- 
equality in  the  surface  of  the  pustule.  On  the  contrary,  the  actions 
being  slower  in  other  parts,  the  pustules  acquire  the  property  of 
common  sloughs,  and  granulation  follows  suppuration  for  the  re- 
storation of  the  lost  part.”f 

According  to  the  observations  of  Cruikshank,  this  white  slough 
is  not  situate  in  the  corion,  but  in  a vascular  membrane  exterior  to 
it,  and  immediately  beneath  the  cuticle.  This  anatomist  macerated 
in  water  for  a week  several  portions  of  small-pox  skin,  which  he  had 
previously  injected,  and  kept  for  some  time  in  spirits.  “ The  spirits 
with  which  they  had  been  impregnated  made  them  resist  the  efiects 
of  this  water  longer.  Cluticle  and  rete  mucosurn  w'ere  already  tuimed 
down ; and  upon  the  eighth  or  ninth  day  I found  I could  separate 
a vascular  membrane  from  the  cutis,  in  which  were  also  situated  the 

* Philosoph.  Transactions,  VoL  LXX.  p.  133.  Mr  Hunter’s  account  of  a woman 
who  had  small-pox  during  pregnancy. 

t Morbid  Poisons,  p.  364, 


524 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


injected  small-pox  pustules.  These  last  consisted  of  circles  of  long 
floating  villi  at  the  circumference,  but  of  a white  uninjected  sub- 
stance in  the  centre.  This  central  part  Mr  Hunter  had  previously 
said  was  a slough  formed  by  the  irritation  of  the  variolous  matter.”* 
He  subsequently  comes  to  the  conclusion,  that  on  the  surface  of  the 
skin  (corion)  lie  five  membranes,  the  outermost  of  which  is  cuticle, 
the  next  two-fold  is  7-ete  mucosurn^  and  the  fourth  is  the  first  vascu- 
lar membrane  in  whicb  the  small- pox  pustules  are  chiefly  seated. 

From  these  facts  and  observations,  as  well  as  those  which  it  has 
occurred  to  myself  to  make,  the  following  conclusions  may  be  drawn. 

The  phlyctidium  or  pustule  of  small-pox  consists  of  a cutaneous 
inflammation,  which  may  produce ; — 

Is?,  Secretion  of  puriform  fluid  without  permanent  injury  or  de- 
struction of  the  corion.  In  lenticular  chicken-pox,  and  distinct 
small-pox,  there  is  no  doubt  tliat  though  suppuration  takes  place 
from  the  cuticular  surfoce  of  the  corion,  it  is  not  necessarily  con- 
nected with  destruction  or  ulceration  of  that  membrane. 

2d,  Suppurative  iilceration  of  the  corion.  In  conoidal  chicken- 
pox,  in  some  instances  of  distinct  small-pox,  and  in  many  instances  of 
small-pox  partially  or  wholly  confluent,  each  pock  proceeds  to  ul- 
ceration of  the  corion.  It  does  not  appear  that  the  pock  slough  de- 
scribed by  Hunter  is  present  in  every  case.  It  is  admitted  by  Adams 
to  be  wanting  in  the  vesicular  small-pox,  which  appear  after  cow- 
pox,  and  in  some  other  occasions. 

3fZ,  Death  of  numerous  spots  of  the  corion  constituting  sloughs. 
In  some  cases  of  distinct  small-pox  this  has  been  observed  ; but  it 
is  most  frequent  in  tbe  confluent  eruption.  It  then  appears  in  the 
form  of  a white  circular  patch  lying  at  the  bottom  of  each  pock. 

4?A,  Along  with  sloughs  at  individual  points,  an  extensive  spread- 
ing redness  of  the  skin  rapidly  terminating  in  sloughs  of  irregular 
shape  and  limits  not  unfrequently  occurs  in  certain  bad  forms  of 
variolous  eruption. 

b.  Oriental  plague  I place  among  the  examples  of  pustular  cuta- 
neous inflammation,  because  the  carbuncle  to  which  its  poison  gives 
rise,  is,  I conceive,  an  instance  of  punctuate  inflammation  of  the 
corion.  I am  aware  that  Willan,  and  after  him  Bateman,  placed 
this  disease  among  the  order  of  tubercular  eruptions.  But  this 
they  have  done,  I am  satisfied,  without  due  consideration  either  of  -- 
the  characters  of  the  pestilential  carbuncle,  or  of  those  which  they 
assign  to  the  order  of  tubercles. 

* Experiments,  &c.  p.  41. 


SKIN. 


525 


From  careful  comparison  of  the  most  authentic  accounts  of  pes- 
tilential carbuncle,  it  commences  as  an  inflamed  spot  in  the  corial 
surface  and  substance.  The  inflammation  of  the  surface  speedily 
induces  sero-albuminous  secretion  and  detachment  of  the  cuticle, 
which  is  elevated  in  the  form  of  a bluish  irregular  blister ; while  be- 
yond this  the  skin  is  of  a fiery-red  colour,  hard,  and  the  seat  of 
searing  pain.  The  simultaneous  inflammation  of  the  corial  sub- 
stance speedily  kills  that  membrane,  which  is  then  felt  in  the  form 
of  a hard  black  mass,  surrounded  by  living  but  highly  inflamed 
skin.  This  dead  portion  is  afterwards,  if  the  patient  survive,  de- 
tached in  the  form  of  a mortified  slough.  The  carbuncle  of  oriental 
plague  seems  not  to  be  quite  similar  to  the  ordinary  carbuncle  seen 
in  this  country. 

c.  Of  the  disease  termed  malignant -pustule  by  the  French,  and  Milz- 
brand,  and  Black -Pocks  by  the  German  authors,  (^Anthrahion ; Nar 
al-Parsi ; Persian  fire,)  we  can  scarcely  speak  from  experience  in 
this  country,  in  which,  so  far  as  I am  aware,  the  disease  is  unknown. 
From  the  description  given  by  Enaux  and  Chaussier,  Vicq-D’Azyr, 
Pinel,  Ozanam,  Rausch,  Hoffmann,*  and  Regnier,f  it  appears  to 
consist  in  inflammation  of  the  outer  surface  of  the  corion,  speedily 
depriving  that  membrane  of  its  vitality.  It  may  commence  in  one 
of  two  modes ; First,  as  a hard,  red,  burning,  not  elevated  point, 
speedily  causing  bluish  or  reddish-blue  fluid  secretion,  elevating  the 
cuticle  into  a purple  or  pale-blue  blister,  {plilyctuena  ;)  Secondly, 
as  a bard,  knotty  substance  slightly  elevated  into  a doughy  swell- 
ing, and  causing  detachment  of  the  cuticle  by  similar  effusion.  In 
both  cases  the  affected  corion  undergoes  mortification,  partial  or  ge- 
neral, and  is  then  detached  as  a foreign  body.  In  some  respects 
this  resembles  the  ordinary  carbuncle  of  this  country.  But  it  dif- 
fers particularly  in  this,  that  the  malignant  pustule  {anthrakion,)  is 
ascribed  by  the  best  authorities  to  contagion,  and  very  often  is 
traced  to  epizootic  contagion,  or  pestilence  occurring  among  the 
lower  animals.  Its  presence  depends  on  the  local  application  of 
a morbid  animal  poison. 

d.  The  great  pock,  (ecthyma,)  consists  in  an  eruption  of  red,  hard, 
sore  pustules,  {phlyzacia,)  distinct,  seldom  numerous,  without  pri- 
mary fever,  and  not  contagious.  In  the  three  species  of  ordinary 

* Der  Milzbrand,  oder  Contagiose  Caifunkel  der  Menschen.  Von  Johann  Frie- 
drich Hoffmann,  Oberwundarzt  in  Bemburg.  Stuttgart,  1827.  8. 

De  la  Pustule  Maligne,  ou  Nouvelle  Expose  des  Phenomenes  observes  pendant 
son  cours,  Par  J.  B.  Regnier  de  Semur,  Cote-d’or,  D.  M.,  &c.  Paris,  1829.  8. 


526 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


{E.  vulgare),  infantile  (^E.  infantum)^  and  dingy  pock  {E.  luridwnri), 
the  pustules  are  round  or  oval  hard  masses  fixed  in  the  substance 
of  the  skin,  which  is  red,  hard,  and  swelled,  and  terminating  first 
in  elevation  and  desquamation  of  the  cuticle,  and  then  in  imperfect 
softening,  discharging  a serous  and  generally  blood-coloured  fluid, 
which  concretes  into  a foul  dark-brown  or  reddish  scab,  which  at 
length  drops  off,  leaving  the  subjacent  skin  reddish,  and  marked 
by  a depressed  scar,  indicating  the  affection  of  the  corial  substance. 

It  seems  probable  that  these  ecthymatous  pustules  may  occasion- 
ally be  seated  in  the  sebaceous  follicles.  If  so  they  ought  to  be  ar- 
ranged under  the  following  head. 

§ 7.  Cutaneous  inflammations  originating  in  the  substance  of  the 
corion^  sometimes  at  the  bulbs  of  the  hair^  sometimes  in  the  cutaneous 
follicles,  terminating  in  "partial  or  imperfect  suppuration,  with  forma- 
tions of  scales,  crusts,  and  occasionally  sloughs,  and  more  or  less  de- 
struction of  the  corial  tissue. 

The  pathological  reader  may  perceive  that  the  last  disease,  which 
came  under  consideration,  forms  a preparatory  step  to  those  of  the 
present  order.  The  hard  phlyzacious  pustules,  by  which  it  is  dis- 
tinguished, denote  a more  complete  affection  of  the  corial  substance 
than  is  known  to  take  place  in  any  previous  cutaneous  inflammation; 
while  the  slow,  crude,  and  imperfect  solution  which  they  undergo, 
and  the  discharge  of  blood-coloured  rather  than  purulent  fluid,  in- 
dicate a variety  of  the  inflammatory  process  different  from  those 
already  examined,  and  approaching  to  those  now  to  follow.  The 
transition,  therefore,  if  not  insensible,  is  at  least  natural,  to  a tribe 
of  diseases  of  which  the  general  character  is  inflammation  of  the 
corion,  which,  modified  in  various  ways,  gives  rise  to  the  varieties 
of  disease  referred  to  this  kind.  The  principal  modifying  circum- 
stances may  be  referred  either  to  duration,  to  circumscription,  to 
difference  in  kind,  or  to  the  integral  elements  of  the  skin  affected. 

1.  The  influence  of  duration  is  observed  in  the  comparative  dif- 
ference of  progress  of  the  common  boil,  which  is  rapid,  and  that  of 
the  whelk  {acne'),  canker  (lupus),  and  yaws  (framboesia),  which  arc 
slow  and  tedious.  2.  The  influence  of  circumscription  or  diffusion 
is  evinced  in  those  inflammations  which  are  confined  to  a spot,  and 
those  which  spread  to  some  extent.  In  the  whelk  and  boil  the  in- 
flammatory process  is  restricted  to  one  point ; in  carbuncle,  on  the 
other  hand,  it  affects  a great  extent  of  the  corion  through  its  entire 
thickness.  3.  Whether  the  inflammation  of  the  corial  substance  be 
different  in  one  disease  from  what  it  is  in  another,  there  are  few  means 


SKIN. 


527 


of  ascertaining.  Though  various  facts  seem  to  indicate  something 
of  this  nature,  too  little  is  known  to  justify  positive  conclusions. 

a.  The  boil  or  bile  (Die  Beule;  Furunculus;  le  Clou;  il  Ciccione;) 
may  be  adduced  as  an  instance  of  acute  inflammation  of  the  corion 
confined  to  a certain  spot.  Pearson  admits  that  its  seat  is  the  skin ; 
but,  by  afterwards  saying  that  it  may  occur  in  any  part  which 
abounds  in  cellular  membrane,  leaves  the  alternative  either  that 
skin  contains  this  substance  abundantly,  or  that  boils  may  occur  in 
many  other  tissues.  Boyer,  by  placing  its  seat  in  the  cellular  tis- 
sue, confounds  it  with  phlegmon.  The  opinion  of  Bichat  diflFers 
from  either,  but  partakes  of  both.  This  anatomist  represents  the 
corion  to  be  penetrated  by  a great  quantity  of  cellular  tissue,  which 
fills  its  areolcB,  and  is  the  exclusive  and  proper  seat  of  the  boil. 
The  truth  of  this  opinion  depends  on  the  idea  attached  to  the  term 
cellular  tissue.  If  by  this  be  meant  the  loose  fatty  matter  with  its 
intersecting  threads,  on  which  the  inner  surface  of  the  corion  rests, 
the  opinion  is  erroneous ; for  this  is  the  proper  subcutaneous  cel- 
lular tissue.  To  this,  doubtless,  the  inflammatory  action  of  boil 
may  descend ; but  the  phenomena  and  termination  of  the  disease 
show,  that  it  consists  at  first  of  circumscribed  inflammation  of  the 
corial  substance,  soon  but  slightly  aflfecting  the  subjacent  cellular 
tissue.  The  circumstances  which  indicate  the  corion,  or  its  follicles, 
as  the  seat  of  furuncular  inflammation  are, — the  defined  knotty  tu- 
mour with  which  the  complaint  begins,  the  minute  pustule  to  which 
it  gives  rise,  and  the  imperfect  and  tardy  suppuration  with  formation 
of  sloughs,  and  the  perforated  appearance  of  the  skin. 

In  various  instances  the  presence  of  boils  seems  to  depend  on  a 
peculiar  aflfection,  either  of  the  sebaceous  follicles,  or  of  the  pilipa- 
rous  sacs.  A sebaceous  follicle  becomes  inflamed,  and  is  affected 
by  mortification.  It  then  requires  to  be  ejected  as  a dead  substance ; 
and,  to  accomplish  the  object,  suppuration  is  excited  all  round.  This 
is  a frequent  cause  of  cutaneous  boil.  The  core,  as  it  is  called  by 
.surgeons,  is  the  mortified  sebaceous  follicle. 

Of  the  same  nature  and  tendency  is  inflammation  of  a hair-sac 
or  bulb.  When  this  takes  place,  it  is  much  disposed  to  cause  death 
in  the  sac  or  bulb,  or  both.  Or  one  hair-sac  or  bulb  may  be  at 
once  smitten  with  death,  and  then  it  equally  acts  as  a foreign  body ; 
and,  to  accomplish  its  ejectment,  suppuration  is  excited.  The  fre- 
quency, with  which  boils  are  observed  to  originate  round  hairs,  is 
familiar  to  many  observers. 

It  is  further  to  be  remarked,  that  the  boil  of  the  sebaceous  fol- 


528 


GENERAL  AND  rATHOLOGlCAL  ANATOMY, 


licle  is  often  induced  by  full  or  rather  gross  living,  by  the  transi- 
tion from  moderation  to  some  degree  of  excess  ; and  sometimes 
boils  are  critical,  as  in  diseases  of  the  lungs,  and  in  some  of  those  of 
the  alimentary  canal. 

b.  Of  the  same  nature  are  the  inflammatory  tumours  termed  Epi- 
nyctis  and  Terminthus  mentioned  by  all  authors  almost  from  Celsus 
to  Wiseman. 

c.  Though  in  this  place  I notice  carbuncle  as  an  example  of  spread- 
ing inflammation  of  the  substance  of  the  corion,  yet  the  question 
of  its  precise  seat  is  not  free  from  ambiguity.  Hunter  believed  it 
to  begin  in  the  skin,  and  going  deeper  to  affect  principally  the  cel- 
lular membrane,  in  which  it  caused  mortification ; and  with  this 
Pearson  agrees.  Boyer  places  it  in  the  integuments  and  subcuta- 
neous cellular  tissue ; while  Monteggia,  who  repeats  the  fact  that 
it  destroys  a considerable  portion  of  the  teguments  and  cellular 
substance  down  to  the  muscles,  seem  to  regard  it  as  a peculiar 
action  affecting  several  tissues  simultaneously  and  successively. 

The  statement  of  Hunter  I was  at  one  time  disposed  to  regard 
as  exhibiting  a just  view  of  the  pathology  of  carbuncle,  and  to 
think  that  Willan  laboured  under  a mistake  in  referring  the  seat 
of  carbuncle  to  the  skin.  From  observing  the  progress  of  several 
carbuncles  from  their  origin  to  their  termination,  and  from  cutting 
them  open  more  than  once  and  examining  their  morbid  relations 
as  carefully  as  it  is  possible  to  do  in  the  living  body,  I am  satisfied 
that  the  opinion  of  Hunter  is  not  correct,  and  that  that  of  Willan 
is  not  altogether  wrong.  In  several  carbuncles  which  I have  ob- 
served from  the  beginning,  the  inflammatory  action  commenced  in 
the  skin  in  the  form  of  a hard  knotty  pustule ; a circumstance 
which  corresponds  with  the  admission  of  Hunter.  If  cut  open  at 
this  time,  which  may  be  done  not  only  with  safety,  but  with  benefit, 
the  corion  is  found  to  be  thicker  than  natural,  much  redder,  and 
more  vascular  ; and  these  marks  of  inflammation  pervade  not  only 
the  substance  of  the  corion  to  a considerable  extent,  but  the  sub- 
cutaneous cellular  membrane  in  a slighter  degree.  This  inflam- 
mation of  the  cellular  membrane  spreads  indeed  along  with  that 
of  the  skin  ; but  it  also  kills  this  tissue  almost  immediately,  or  at 
least  speedily  gives  it  the  usual  appearance  of  mortified  matter. 
At  the  same  time,  the  inflammation  of  the  corion  extending  quickly, 
kills  at  least  its  exterior  surface  ; and  Hunter  is  inaccurate  in  say- 
ing that  the  skin  does  not  die,  but  gives  way  by  ulceration.  Death 
of  the  corion  is  an  early  effect  of  carbuncular  inflammation  ; and 


SKIN. 


529 


though  it  does  not  preclude  the  formation  of  ulcerated  openings, 
it  may  take  place  without  them.  According  to  my  own  observa- 
tion, death  takes  place  most  generally  in  patches  of  the  corion, 
which  may  afterwards  burst  as  it  were  by  distension  ; ulceration 
takes  place  at  points  which  have  not  been  killed,  and  in  general  at 
the  union  of  the  dead  and  living  skin. 

There  is  no  ground  for  believing  that  the  subcutaneous  cellular 
membrane  is  killed  by  the  confinement  of  matter  in  its  cells,  as 
Hunter  imagines.  The  ordinary  mode  in  which  this  appears  to 
take  place  is  by  tbe  spreading  inflammation  of  the  corion,  extending 
along  its  lower  surface,  and  producing  death,  as  it  appears  to  do 
in  diflPuse  inflammation,  in  which  it  spreads  and  does  not  readily 
cause  suppuration. 

Upon  the  whole,  it  may  be  concluded  that  the  corion  is  the  pri- 
mary seat  of  disease  in  carbuncle,  and  that  the  affection  of  the  cel- 
lular membrane,  with  which  it  is  uniformly  accompanied,  is  the  ef- 
fect of  inflammation  of  the  corial  tissue  spreading  to  the  adipose 
membrane. 

4.  Diseases  affecting  chiejiy  the  sebaceous  follicles. — These,  which 
are  acne,  sykosis,  and  molluscum.i  show  the  influence  of  texture  or 
the  elements  of  the  skin  affected. 

The  whelk  {acne ; ionthos  ; varus,  vari,  Celsus ;)  consists  of  mi- 
nute portions  of  corion,  round,  oval,  or  spheroidal,  hard,  circum- 
scribed, and  elevated.  Of  the  four  sorts  enumerated  by  Bateman, 
three  only,  the  simple  (A.  simplex),  the  inveterate  {A.  indurata), 
and  the  crimson  (A.  rosacea)^  can  be  considered  as  examples  of  in- 
flammation of  the  substance  of  the  corion  ; and  even  these  are  affec- 
tions of  the  cutaneous  follicles. 

d.  Acne  simplex  and  Acne  indurata  are  manifestly  affections  seat- 
ed in  the  sebaceous  follicles  of  the  skin,  and  appear  to  consist  partly 
in  changed  secretion  in  the  surface  of  these  minute  glands,  partly 
in  chronic  inflammation  of  the  substance  of  the  glands. 

They  may  appear  either  on  the  face  or  on  the  person.  Their 
character  is  that  of  small  tumours  or  tubercles,  mostly  ovoidal,  si- 
tuate in  the  follicles,  the  orifices  of  which  are  swelled  and  closed. 
They  are  chronic  in  duration  and  slow  in  progress ; and  often, 
when  they  begin  to  appear,  they  continue  to  distress  the  patient  for 
years.  Their  appearance  is  believed  to  be  connected  with  some 
deranged  state  of  the  alimentary  function. 

When  this  eruption  appears  on  the  person,  it  is  chiefly  the  pos- 

L 1 


530 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


terior  surface  of  the  trunk  which  the  pustules  occupy.  They  then 
appear  in  the  form  of  oblong  ovoidal  tubercles,  with  the  long  dia- 
meter corresponding  to  the  axis  of  the  body.  There  also  they  are 
slow  in  progress.  It  is  possible  by  a glass,  sometimes  by  the  eye,  to 
recognize  the  orifice  of  the  follicle  closed ; and  the  follicle  swelled 
and  enlarged  all  round.  In  general  these  swellings  undergo  slow 
and  partial  suppuration  ; and  in  some  severe  cases,  the  follicle  is 
mortified  and  ejected  by  suppuration,  like  a'  part  deprived  of  life. 

Both  the  simple  and  indurated  whelk  may  produce  ulcerative 
destruction  of  the  true  skin,  and  leave  a smooth  depressed  scar ; 
and  I have  seen  them  by  extending  to  the  roots  of  the  hairs  ren- 
der the  skin  entirely  depilous. 

The  black  whelk  (Acne  punctata),  doubtless  arises  from  disease 
and  obstruction  of  the  mucous  follicles,  or  sebaceous  glands. 

Demodex  Folliculorum.  Follicular  worm. — A singular  circum- 
stance relating  to  the  sebaceous  follicles  of  the  face  and  their  dis- 
eases, is  the  fact  that  they  become  the  residence  of  a peculiar  spe- 
cies of  parasitical  animal  or  worm,  not  dissimilar  in  appearance  to 
the  grub  of  a common  fly.  The  existence  of  this  animal  in  the 
sebaceous  follicles  of  the  face  was  first  discovered  in  1842  by  Dr 
Simon  of  Berlin  ;*  and  since  that  time  it  has  been  repeatedly  seen 
by  observers  in  this  city,  and  is  fully  described  by  Mr  Owen. 

The  animal  belongs  to  the  lowest  organized  forms  of  the  order 
Arachnida ; and  like  the  parasitic  Cymothoe  and  Bopyrus  of  the 
Crustaceous  class,  makes  a transition  from  the  Annelides  to  the 
higher  Articulata.  In  length  the  animal,  which  has  been  named 
the  Demodex  folliculorum,  ranges  from  one-fiftieth  to  one-hundredth 
part  of  one  inch.  The  head  and  mouth  are  confluent  with  the  ab- 
domen. The  thoracic  appendages,  eight  in  number,  as  in  the  Ai’- 
ticulata,  are  simple  and  rudiniental,  and  are  terminated  by  three 
short  setoe.  The  integument  of  the  abdomen  is  minutely  annulat- 
ed.  The  mouth  is  suctorial  and  proboscidiform.  The  entozoon 
occupies  the  hair  follicles  and  the  sebaceous  follicles.f 

e.  The  crimson  whelk  (A.  rosacea,  gutta  rosea  ; dartre  pustuleuse 
couperose  of  Alibert),  is  an  affection  rather  complicated ; and  I 
doubt  whether  it  is  justly  classed  with  those  now  mentioned.  It  is 
doubtless  an  affection  of  the  corial  substance ; but  it  commences 

* Muller’s  Archiv  fur  Physiologie.  Berlin,  1842.  P.218. 

t Lectures  on  the  Comparative  Anatomy  and  Physiology  of  the  Invertebrate  Ani- 
mals. By  Richard  Owen,  Esq.  &c.  London,  1843. 


SKIN. 


531 


with  redness  and  slight  diffuse  swelling  of  the  skin  of  the  nose  and 
cheeks,  not  unlike  that  of  erythema  marginatum.  This  is  followed 
by  the  appearance  of  two  or  three  small  seedy  particles  very  hard, 
but  red  and  tending  to  suppurate,  which  they  at  length  do  partial- 
ly at  their  summits,  while  the  base  remains  hard,  red,  and  firm. 
As  the  red  appearance  of  the  skin  spreads,  the  roughness  increases  ; 
fresh  particles  of  the  same  seedy  consistence  arise  and  undergo  the 
same  course;  and  some  coalescing  form  broad  tubercular  blotches 
of  a crimson  or  livid  colour,  and  irregular  notched  surface.  The 
skin  is  not,  however,  in  this  state  at  all  times  permanently  red.  I 
have  seen  this  affection  in  patches  on  the  cheeks  and  nose  so  light 
coloured,  that  in  the  morning  it  could  not  be  recognized ; but  in 
the  latter  part  of  the  day,  after  taking  wine,  and  becoming  warm, 
they  assumed  an  intense  red  inclining  to  crimson.  In  the  advanced 
stage,  when  numerous  tubercles  appear,  and  the  surface  is  gene- 
rally rough  and  red,  the  skin  swells  diffusely  and  becomes  doughy, 
and  is  traversed  by  tortuous  purple  veins  ; the  nose  is  enlarged ; the 
nostrils  become  distended,  their  surface  notched  into  lobular  masses ; 
the  red  hard  bodies  of  the  cheeks  become  large  and  coherent ; and 
the  whole  countenance  is  converted  into  a crimson  tumid  mass,  in 
which  the  original  features  are  prodigiously  deformed.  These 
whelks  do  not  often  undergo  suppuration,  but  are  constantly  cast- 
ing the  cuticle  in  the  form  of  peelings,  or  scales,  or  crusts.  When 
suppuration  occurs  it  is  liable  to  terminate  in  bad  and  intractable 
sores. 

f.  The  chin  and  scalp  whelk,  (Sykosis  ; Mentagra  ; dartre  pustu- 
leuse  mentagre,)  consists  in  chronic  pustular  inflammation  of  the 
substance  of  the  corion  at  the  bulbs  or  conduits  of  the  hairs,  and 
probably  of  various  sebaceous  follicles  besides.* 

g.  On  the  subject  of  molluscum  contagiosum  much  information  has 
been  recently  communicated  by  the  researches  of  Dr  Robert  Pater- 
son, Dr  Reid,  and  Dr  A.  Thomson. 

According  to  the  observations  of  Dr  Paterson  the  appearance  of 
the  bodies  commences  in  the  shape  of  minute  pearly  granulations, 
which  increasing  in  size,  become  more  of  the  natural  colour  of  the 
skin.  When  as  large  as  a vetch,  on  their  apices  appears  an  open- 
ing emitting  a whitish  milky  fluid.  Their  size  varies  from  a pin- 
head to  that  of  a hazel-nut ; and  their  progress  in  attaining  the 
largest  size,  though  varying,  is  slow. 

* Celsi,  Lib.  vi.  3. 


532 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


The  structure  of  the  small  bodies  is  that  of  numerous  cells  se- 
creting the  milky  fluid,  which  under  the  microscope  is  entirely  com- 
posed of  nucleated  cells  oblong  or  ovoidal  in  shape.  These  are 
about  one- thousandth  part  of  one  inch  in  diameter.* 

From  the  position  which  the  tubercles  of  contagious  molluscum 
occupy  in  the  face,  it  seems  certain  that  they  are  seated  in  the  fol- 
licles. They  are  generally  found  round  the  lips,  or  on  the  chin, 
near 'the  nose,  and  in  those  situations  in  which  the  follicles  are 
mostly  placed. 

h.  The  chronic  soft  tubercle  {rnolluscum  diuturnurn)^  is  a rare 
disease  ; and  I have  seen  only  one  example  of  it  in  the  person  of  a 
man  of  40,  in  whom  these  bodies  were  disseminated  over  the  cu- 
taneous surface  of  the  face  and  scalp,  the  trunk,  the  upper  extre- 
mities, the  nates  and  thighs.  Of  two  of  the  larger  tumours  which 
were  removed  from  the  palpehi'ce^  the  greater  part  was  composed 
of  firm,  tough,  whitish  gray  matter  of  the  consistence  of  condensed 
cellular  texture,  penetrated  through  its  whole  extent  by  numerous 
minute  blood-vessels,  but  exhibiting  in  no  other  respect  traces  of  or- 
ganization. This  substance,  when  macerated  in  water,  was  resolved 
into  gelatinous,  flocculent  filaments,  easily  lacerable,  and  present- 
ing no  definite  sti’ucture.  Imbedded  in  this,  and  removable  most 
easily  by  maceration,  were  several  small  bodies  not  larger  than  a 
pin-head  like  fat  in  appearance,  of  a regularly  spheroidal  shape,  of 
a lemon-yellow  colour,  and  specifically  lighter  than  water.  The 
matter  of  these  bodies  was  unctuous.  It  communicated  an  oily 
stain  to  paper  ; it  liquefied  and  became  transparent  at  a temperature 
not  exceeding  97°  Fahrenheit,  so  that,  when  attached  to  the  body,  it 
must  have  been  fluid ; it  was  insoluble  in  alcohol,  ether,  and  water, 
but  formed  in  the  volatile  oil  of  turpentine  a colourless  solution. 
When  this  was  exposed  to  the  temperature  of  the  spirit-lamp,  the 
greatest  part  of  the  volatile  oil  was  evaporated,  leaving  a transpa- 
rent, colourless,  but  viscid  and  semifluid  substance,  communicating 
to  paper  a stain  becoming  less  deep,  but  not  wholly  removable  by 
exposure  to  a high  temperature.  These  results  favour  the  idea 
that  the  matter  of  these  bodies  is  oleaginous;  but  I was  unable  to 
observe  any  action  of  aqua  potasscB  or  aqua  ammonia,  after  repeated 

■*  Cases  and  Observations  on  the  Molluscum  Contagiosum  of  Bateman,  \vith  an  Ac- 
count of  the  Minute  Structure  of  the  Tumours.  By  Robert  Paterson,  M.  D.  Edin- 
burgh Medical  and  Surgical  Journal,  Vol.  LVI.  p.  279.  Edinburgh,  1841. 

f Du  Molluscum  Recherches  Critiques  sur  les  formes,  la  nature,  et  le  traitement  des 
AlFections  Cutanees  de  ce  nom.  Par  Maximihan-Maurice  Jacobovics,  Docteur  Me- 
decin  de  la  Faculte  de  Pesth.  Paris,  1840,  8vo. 


SKIN. 


533 


trials,  both  at  the  ordinary  temperature  of  the  atmosphere,  and 
when  liquefied  by  a gentle  heat.  By  the  sulphuric  acid  it  is  har- 
dened  and  blackened;  by  the  nitric  acid  its  yellow  colour  is  rendered 
more  intense.* 

Whether  the  presence  of  these  yellow  adipocirous  bodies  is 
uniform  in  the  molluscum  I have  had  no  subsequent  means  of  ascer- 
taining. If  they  are,  it  may  be  reasonably  conjectured,  that  their 
formation  depends  on  some  morbid  or  vitiated  state  of  the  sebaceous 
follicles.  I have  indeed  no  doubt  that  in  the  case  referred  to  the 
small  tumours  consisted  in  lesion  of  the  cutaneous  follicles. 

i.  Under  the  head  of  canker,  lupus ^ (iioli  me  tangere^  wolf  of 
Wiseman  and  others,  dartre  rongeante,  Pinel  and  Alibert,)  may  be 
noticed  a disease  consisting  in  hard  elevated  tubercles  set  in  the 
corion,  from  which  they  appear  to  grow.  The  name  of  noli  me 
tangere  is  applied  by  Wiseman  to  a “ small  round  acuminated 
tubercle”  without  much  pain,  unless  when  “ touched,  rubbed,  or 
otherwise  exasperated  by  topics.”  Though  most  frequent  on  the 
face,  it  may  occur  on  other  parts.  One  of  these,  of  a bluish 
colour,  and  looking  like  a vein,  appears  from  the  description  to 
have  been  of  the  nature  of  erectile  tissue. 

One  example  of  bluish  spherical  tubercle  I have  seen  in  the 
person  of  a woman  of  about  65  years  of  age,  otherwise  healthy. 
It  was  situate  on  the  side  of  the  nose  near  the  middle  of  the  nasal 
bone.  It  appeared  first  in  the  form  of  a small  red  prominence  less 
than  a pea,  but  gradually  shot  up  from  the  skin,  so  as  in  the  course 
of  twenty  months  or  two  years  from  its  commencement,  to  project 
at  least  one-third  of  an  inch  from  the  surrounding  skin.  It  was 
then  round  or  spherical,  smooth,  and  even  shining,  and  of  a blue 
or  light  purple  colour,  which,  on  close  examination,  wms  derived 
from  numerous  minute  vessels.  It  was  connected  to  the  skin  by  a 
neck,  the  base  being  narrower  than  the  summit,  but  did  not  adhere 
to  the  bone.  What  was  the  ultimate  fate  of  this  person  I did  not 
learn ; but  no  doubt  can  be  entertained  that  if  life  were  continued 
a sufficient  time,  the  tubercle  would  terminate  in  destructive  fun- 
gating ulceration. 

I have  seen  also  many  cases  of  ragged  ulceration  of  the  coun- 
tenance, and  one  or  two  in  the  incipient  state  before  it  spread  to 

• A good  painting  of  the  subject  of  this  case  was  made  by  my  late  friend,  Staff- 
Surgeon  Schetky,  and  by  him  deposited  in  the  pathological  collection  of  Chatham 
Hospital. 


534 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


any  extent.  One  mode  in  which  this  disease  appears  to  commence 
is  by  the  formation  of  a patch  of  hard  red  skin,  slightly  but  diffusely 
swelled,  and  which  is  the  seat  of  a hot,  gnawing,  smarting  sensa- 
tion. Though  smooth  on  the  surface,  it  is  found  by  examination 
to  be  irregular,  or  very  soon  becomes  so  by  the  formation  of  small 
hard  round  bodies,  (pustulo-tubercular),  which  after  some  time  begin 
to  be  acuminated,  and  cast  the  cuticle  in  thin  peelings.  Occasion- 
ally they  give  rise  to  thin  watery  vesicles  of  no  determinate  shape, 
which  cither  burst  the  cuticle  and  discharge  their  fluid,  or  appear 
to  cause  an  insensible  dewy  oozing  all  over  the  surface.  The  most 
usual  seat  of  this  form  of  cutaneous  inflammation  is  the  side  of  the 
nose,  one  of  the  alae^  or  a small  portion  of  the  cheek.  After  sub- 
sisting in  this  form  for  some  time,  it  may  disappear  spontaneously, 
the  skin  becoming  of  its  natural  colour,  soft  and  without  pain. 
More  frequently,  however,  the  cuticle  continues  to  be  cast  off  in 
peelings ; vesicles  and  pustules  continue  to  be  formed  ; and  one  or 
other  more  red  and  painful  than  the  rest  is  at  length  covered  by  a 
scab,  which  dropping  off  discloses  a small  sore  with  a smooth  un- 
granulating surface,  and  a scanty,  thin,  bloody-coloured,  puriform 
discharge,  which  generally  forms  a fresh  crust  or  scab.  This  either 
spreads  without  showing  any  disposition  to  heal,  or  coalesces  more 
or  less  completely  with  other  sores  which  are  generated  in  the  same 
mode,  and  undergo  the  same  process.  After  proceeding  in  this 
manner  for  weeks  or  months,  a tendency  to  heal  is  manifested  in 
some  parts,  while  others  continue  to  spread.  The  parts  which  heal 
are  irregularly  seamed  and  scarred.  This  form  of  disease  appears 
to  correspond  with  what  Wiseman  describes  under  the  name  of 
Herpes  Exedens. 

k.  Another  form  of  local  pustulo-tubercular  disease  I have  seen 
take  place  on  the  skin  of  the  face,  generally  on  the  forehead,  in 
the  form  of  round  hardish  bodies,  with  flat  summits,  to  the  number 
of  eight,  ten,  or  twelve,  disposed  in  a circular  arrangement.  The 
surface  of  the  skin  was  red,  glossy,  and  occasionally  casting  cuti- 
cular  scales  and  shreds.  These  bodies  were  stated  to  be  the  seat 
of  an  uneasy  sensation  of  heat  rather  than  of  pain.  They  had 
not  advanced  to  ulceration.  Upon  removal  by  the  knife,  they  be- 
came pale,  white,  and  considerably  shrunk.  Internally  they  con- 
sisted of  gray  coloured  substance,  interspersed  with  a few  blood- 
vessels, not  hard,  so  much  as  doughy,  tough,  and  fibro-cartilagi- 
pous.  They  did  not,  nevertheless,  present  the  characters  of  car- 

1 


SKIN. 


535 


cinoma,  but  seemed  to  consist  in  an  inflammatory  induration  of  the 
corial  tissue. 

On  the  anatomical  characters  of  the  white  scall  (vitiligo)^  I 
possess  no  accurate  information.  I have  often  suspected  that  the 
appearances  referred  to  this  disease  are  in  truth  the  effects  of  others 
more  known. 

1.  (Yaws)  {frambcesia\  consist  in  chronic  inflammation  of  the 
corion  taking  place  in  circumscribed  spots,  attended  partly  with  death 
of  a portion  of  the  corial  substance,  partly  with  growth  of  granular 
fungi, — the  result  of  a peculiar  morbid  poison. 

On  the  nature  and  characters  of  this  disease  much  misconception 
has  prevailed,  chiefly  fi'om  the  erroneous  notions  to  which  its  sta- 
tion, in  the  arrangement  of  Cullen,  gave  birth.  These  were  first 
corrected  in  1791  by  Dr  Jonathan  Anderson  Ludford,  who  showed 
that  yaws  is  a true  cutaneous  inflammation,  which,  though  more 
chronic,  yet,  like  small-pox  and  other  acute  cutaneous  eruptions,  is 
preceded  by  febrile  motions,  and  observes  regular  periods  of  acces- 
sion, height,  and  decline.*  The  general  accuracy  of  these  facts  has 
been  confirmed  bythe  testimonyof  Dr  William  Wright,  f Dr  Winter- 
bottom,!  Dr  Joseph  Adams,§  and  Dr  James  Thomson,  ||  who  ob- 
served the  phenomena  of  the  disease  in  negroes  or  Europeans  in 
the  West  Indies  or  elsewhere.  Dr  Dancer,  who  admits  that  they 
seldom  make  their  appearance  without  previous  indisposition,  alone 
doubts  the  propriety  of  comparing  them  with  small-pox  and  other 
eruptions.  IF 

It  cannot  be  doubted,  that  the  appearance  of  yaws  is  invariably 
preceded  by  more  or  less  indisposition, — as  languor,  pains  of  the 
limbs  like  those  of  rheumatism,  chillness  or  shivering  succeeded  by 
general  heat  and  uneasiness,  amounting  in  most  cases  to  fever,  and 
always  more  severe  and  distinct  in  children  than  in  adults.  The 
first  trace  of  eruption  is  a white  mealy  scurf  covering  the  whole 
cutaneous  surface.  A few  days  after  small  firm  pimples  may  be 

• Tentamen  Med.  Inaug.  de  Framboesia  et  Jon.  Ludford  Ed.  1791. 

Apud  Adams  on  Morbid  Poisons. 

X Account  of  the  Native  Africans,  &c.  by  T.  M.  Winterbottom,  M.D.  London, 
1803,  Vol.  II.  c.  viii. 

§ Observations  on  Morbid  Poisons,  &c.  by  Jos.  Adams,  M.D.  2d  Edit.  Lond.  1807, 
chap.  xvi. 

II  Observations  and  Experiments,  &c.  Med.  and  Surg.  Jom'nal,  Vol.  XV.  321,  and 
XVII.  31. 

H The  Medical  Assistant,  &c.  by  Thomas  Dancer,  M.D.  Kingston,  1801,  chap.  ix. 
p.  201.  2d  Edition.  St  Jago  de  la  Vega,  1809.  P.  226. 


536 


GENERAL  AND  PATHOLOGICAL  ANATOJIY. 


seen  on  the  forehead,  face,  neck,  groin,  and  round  the  anus. 
These  increase  for  six  or  ten  days,  when  their  tops  are  covered  by  a 
crust ; and  an  opaque  whitish  fluid,  which  is  ill  formed  matter,  may 
be  recognized.  Thus  converted  into  pustules,  they  gradually  en- 
large, still  covered  by  crusts,  which  are  loose  and  irregular,  until 
they  attain  the  size  of  a sixpence  or  even  of  a shilling, — the  largest 
being  in  general  those  which  apjjeared  first.  If  in  this  state  the 
crust  be  removed,  it  exposes  a foul  sloughy  sore,  or,  according  to 
Adams,  a rough  whitish  surface  consisting  partly  of  slough,  partly 
of  living  animal  matter.  The  pustules  may  also  burst  spontane- 
ously, and  discharge  thick  viscid  matter,  which  hardens  into  a foul 
crust  or  scab  on  the  surface.  In  the  large  pustules  from  this  sur- 
face at  length  shoots  up  a red  granulated  excrescence  composed  of 
minute  lobes,  not  unlike  a wild  rasp  or  mulberry,  which  is  the 
proper  yaw,  and  gives  the  disease  its  peculiar  appearance  and  cha- 
racter. Its  size  varies  according  to  that  of  the  pustule  from  which 
it  rises,  from  a pea  to  that  of  a mulberry  of  considerable  dimen- 
sions. Its  colour  also  varies  according  to  that  of  the  general  health 
of  the  subject.  In  the  healthy  and  robust  it  is  red  like  a piece  of 
flesh  and  prominent ; in  the  weakly  and  puny  it  is  pale  and  white 
like  a piece  of  cauliflower,  not  elevated,  and  bleeds  on  the  slightest 
touch.  The  yaw-fungus  has  little  sensibility,  and  does  not  smart 
when  capsicum-juice  is  applied,  never  suppurates  perfectly,  but 
discharges  a sordid  glutinous  fluid,  which  dries  into  a scab  round 
the  edges  of  the  excrescence  and  covers  its  upper  part,  if  much 
elevated,  with  white  sloughs.  This  glutinous  fluid  is  the  proper 
yawey  matter,  and  communicates  the  disease  by  inoculation. 

The  time  at  which  the  fungous  granulation  rises  is  irregular. 
Thomson  met  with  it  so  early  as  one  month  and  so  late  as  three 
after  the  first  appearance  of  the  eruption ; and  he  concludes  that 
its  formation  cannot  be  taken  as  a mark  of  the  second  stage  of  the 
disease,  as  was  thought  by  Adams.*  Each  pustule,  as  it  attains  a 
certain  size,  undergoes  the  same  process.  After  remaining  some 
time,  the  yaw  gradually  contracts,  diminishes  in  height,  and,  as  the 
pustule  heals,  is  finally  covered  by  skin.  It  leaves  in  general  no 
mark  except  in  those  places  in  which  inflammation  has  been  violent, 
when  a scar  similar  to  that  of  cow-pock,  but  broader  and  more  su- 
perficial, is  left. 

This  description  shows  not  only  that  yaws  are  an  inflammatory 
* Morbid  Poisons,  p.  201. 


SKIN. 


537 


disease  of  the  skin,  but  that  they  are  not,  strictly  speaking,  an  ex- 
ample of  tubercular  disease  of  that  membrane,  as  in  the  arrange- 
ment of  Willan  is  erroneously  represented.  The  phenomena  show 
that  they  consist  in  an  inflammatory  process  of  the  corion,  com- 
mencing in  minute  points,  and  gradually  spreading  in  extent  and 
penetrating  in  depth,  till  it  generates  a peculiar  morbid  product, 
which,  after  undergoing  certain  changes,  is  at  length  spontaneously 
removed,  and  allows  the  sore  to  heal.  Thomson  justly  remarks, 
that  the  disease  is  first  papular,  then  pustular,  and  afterwards  con- 
sists of  yaw,  though  the  latter  is  not  constant,  as  the  ulcer  may 
heal  without  this  substance,  when  it  must  be  accounted  pustular. 
At  no  period  does  it  appear  to  be  tubercular;  for  the  yawey  growth, 
to  wTich  alone  this  term  can  be  applied,  is  rather  an  effect  of  the 
pustular  or  chronic  corial  inflammation  modified  by  the  proper 
yawey  action.  It  may,  in  short,  be  inferred,  that  when  the  yawey 
action  is  sufficient  without  being  excessive,  it  generates  the  proper 
fungous  growths,  under  which  the  corion  is  either  not  materially 
injured  or  is  regenerated ; if  the  action  be  too  violent,  this  growth 
is  either  destroyed  or  prevented  from  appearing ; and  in  either 
case  the  corion  is  irreparably  injured. 

m.  Siwens,  though  a disease  affecting  not  only  the  skin,  but  the 
fibro-mucous  membranes,  is  entitled  to  notice  in  this  place,  as  caus- 
ing cutaneous  inflammation  not  dissimilar  to  that  of  yaws.  Like 
most  inflammations  depending  on  the  action  of  a morbid  poison, 
when  it  affects  the  constitution  it  induces  inflammation  of  the  corion 
in  the  shape  of  pustules  terminating  in  bad  ulceration  and  sloughs, 
— of  furuncular  tubercles  and  ulcers, — and  of  pustular  sores  afford- 
ing the  raspberry  granulating  fungus.  * 

§ 8.  Cutaneous  inflammations,  chronic,  affecting  at  once  the  sur- 
face and  the  substance  of  the  corion,  and  attended  with  general  af- 
fection of  the  fibro-mucous  tissues. 

Of  the  disorders  which  I refer  to  this  head,  several  are  so  similar, 
that  they  are  probably  to  be  viewed  as  varieties  of  the  same  morbid 
action.  Of  this  kind  are  the  Radesyge,  Spedalsked,  Liktraa  or 
northern  leprosy,  the  Pellagra  or  Lombard  evil,  the  Scherlievo  of 
the  same  place  in  Italy,  the  ]\Ial  di  Rosa  of  Asturia,  and  a cuta- 

* Gilchrist  in  Essa)  s and  Observations,  Phys.  and  Lit.  Vol.  III.  Art.  xi.  Ed.  1771. 

Diss.  Inaug.  de  Syphilitide  Insontium,  &c.  Auct.  A.  Freer.  Ed.  1776. 

Cases  in  Surgerv',  &c.  By  James  Hill,  Snrgeon.  Ed.  1772. 

Observations  on  !Morbid  Poisons,  &c.  By  Joseph  Adams,  M.  D.  London,  1807, 
Chap.  XV.  2d  Ed. 


538 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


neous  disorder  prevalent  in  Grim  Tartary.  In  whatever  points 
these  disorders  differ,  all  of  them  agree  in  being  preceded  by  dis- 
tinct febrile  commotion,  in  consisting  of  inflammation  affecting  the 
corion  in  definite  points,  and  in  causing  at  the  same  time  more  or 
less  inflammation,  punctuate  or  diffuse,  of  the  mucous  and  fibro- 
mucous  membranes  of  the  nasal  cavities,  the  throat,  the  Eustachian 
tube,  and  tympanal  cavity. 

In  these  diseases  the  affection  of  the  corion  is  neither  pustular 
nor  tubercular,  but  consists  in  inflammation  of  its  substance  occur- 
ring in  many  minute  points,  and  causing  first  an  appearance  like 
papulae,  or  sometimes  only  an  extensive  diffuse  redness  and  rough- 
ness of  the  skin  ; then  desquamation  of  the  cuticle ; then  pustulo- 
tubercular  or  minute  hard  eminences  seldom  suppurating  com- 
pletely, but  sometimes  causing,  partly  by  sloughing,  partly  by  ul- 
ceration of  the  corion,  deep  foul  sores,  destroying  the  corial  texture 
and  the  bulbs  of  the  hair.  This  is  particularly  the  case  in  the  Ra- 
desyge,  the  form  of  disorder  prevalent  in  Iceland,  the  Scandinavian 
peninsula,  the  Feme  Islands,  and  the  peninsula  of  Jutland.  In 
those  prevalent  in  Italy,  Asturia,  and  Grim  Tartary,  ulceration  of 
the  corion  appears  to  be  less  frequent. 

The  limits  of  this  treatise  do  not  permit  me  to  enter  at  large  into 
the  history  of  these  diseases,  which  are  not  to  be  viewed  as  merely 
cutaneous  affections ; and  I shall  simply  refer  to  the  best  sources 
for  further  information.* 


* For  Radesyge,  Dissert.  Inaug.  de  morbo  cutaneo  luem  veneream  consecutivam 
simulante,  auctore  C.  F.  Ahlander.  Upsaliee,  1806. 

Diss.  Inaug.  sistens  obs.  in  exanthema  arct.  vulgo  Radesyge,  auctore  Isaaco  Vought. 
Gryphese,  1811. 

Geograpbische  Nosologie  von  Fried.  Schnurrer,  M.  D.  p.  440. 

Morbus  quern  Radesyge  vocant,  &c.  Commentatio  Auctore  Fred.  Holst,  M.  D. 
Christianiae,  1817. 

Ueber  die  Aussatzartige  Krankheit  Holsteins,  &c.  Von  Ludwig  Aug.  Struve,  M.  D. 
1820. 

Die  Radesyge  Oder  das  Scandinavische  Syphiloid.  Aus  Scandinavischen  Quellen 
dargestellt.  Von  Dr  Lud\vig  Hiinefeld,  Professor  zu  Greifswalde.  Leipzig,  1828. 
8vo.  ^ 

Erkenntniss  und  Cur  des  Sogenannten  Dithsmarsischen  Krankheit.  Von  Dr  E.  A. ' 

L.  Iliibener,  Pract.  Aertze  en  Heide.  Alton  a,  1835. 

For  Pellagra,  S.  Const.  Titii  orat.  de  Pellagrs  Pathologia.  Viteberg.  1792. 

De  Pellagra  Obs.  quas  collegit  Caietano.  Strambio,  1784-89,  Mediol.  , 

Franc.  Frapolli.  Mediol.  Animadvers.  in  Alorbum  vulgo  Pellagra,  Med.  1771.  jS 
N.  X.  Jansen  de  Pellagra,  Lug.  1787.  Frank  Delect.  Tom.  IX.  p.  325.  ^ 

Holland  in  Medico- Chirurgical  Transactions,  Vol.  VII. 

For  Mai  de  Rosa,  Thierry  Observations  de  Physique  et  Medecine,  Tom.  II.  Chap.  vi.  W- 


SKIN. 


639 


To  this  head  also  may  be  referred  some  of  the  cutaneous  erup- 
tions which  occur  either  among  the  secondary  symptoms  of  syphilis, 
or  in  the  persons  of  those  who,  for  this  disease,  have  been  subjected 
to  one  or  more  courses  of  mercurial  medicines.  Though  these 
eruptions  may  appear  sometimes  in  the  form  of  papules,  sometimes 
as  a variety  of  rupia,  and  sometimes  as  ecthyma,  they  are  also  not 
unfrequently  of  the  chronic  pustulo-tubercular  nature,  originally 
taking  place  in  the  corion,  and  causing  more  or  less  ulceration  of 
that  membrane.  Their  connection  with  inflammation  of  the  mucous 
and  fibro-mucous  membranes  is  well  known. 

Upon  elephantiasis  so  much  accurate  information  has  been  col- 
lected by  Dr  Adams,  Mr  Lawrence,  and  Dr  Lee,  that  little  diffi- 
culty can  be  experienced  in  settling  its  characters  as  a morbid 
state  of  the  skin.  The  case  described  so  well  by  the  last  of  these 
observers,  1 had  repeated  opportunities  of  seeing;  and  the  appear- 
ance of  the  skin  could  leave  no  doubt  of  the  disease  affecting  the 
substance  of  tbe  corion.  The  exact  nature  of  this  affection  is  per- 
haps less  easily  determined.  By  calling  it  a tubercular  eruption, 
after  the  manner  of  Dr  Bateman,  little  exact  information  is  com- 
municated. Bichat  states  that  he  has  seen  the  corion  manifestly 
disorganized  in  elephantiasis,*  but  says  nothing  of  the  anatomical 
characters  of  this  disorganization.  Pinel,  Bedard,  and  Meckel, 
are  equally  silent  on  this  subject.  In  short,  though  we  have  good 
descriptions  of  the  external  visible  appearances  of  Arabian  leprosy, 
an  accurate  description  of  its  anatomical  characters  is  still  a desi- 
deratum. 

Wart  and  corn  are  believed  to  depend  on  morbid  accumulation 
of  cuticle.  The  former,  however,  is  vascular  at  its  basis ; and  it 
may  therefore  be  inferred  that  its  production  depends  on  morbid 
action  of  the  surface  of  the  corion  at  the  particular  point  at  which 
it  appears. 

II.  § 1.  Dermatcemia,  Dermatorrhagia. — Hemorrhage  of  the  skin 
appears  under  two  forms ; either  that  of  a bloody  or  blood-coloured 
fluid  oozing  from  certain  regions,  or  of  blood  eflPused  in  the  form 
of  purple  specks,  spots,  patches,  or  livid  stripes  on  the  surface  of 
the  corion  below  the  scarf-skin.  The  former  discharge  is  rare, 
and  takes  place  chiefly  as  a supplementary  evacuation  to  some  na- 
tural one  accidentally  suppressed,  as  the  menstrual  discharge  in 

For  Scherlievo,  Annali  Universali  de  Medecina. 

For  Grim  Tartary  Disease,  the  Travels  of  Falk,  Gueldenstadt,  and  Pallas. 

* Anat.  Generale,  Tome  IV.  p.'688. 


540 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


females.  The  latter  is  of  a different  nature,  and  is  both  the  effect 
and  proof  of  a morbid  state  of  the  system. 

Restricted  in  this  manner,  hemorrhage  from  the  corion  may 
take  place  in  two  modes ; either  when  the  corion  only  is  affected, 
or  when  it  is  affected  in  common  with  many  other  membranes. 
The  first  case  constitutes  the  simple  purple  disease  {purpura  sim- 
plex) of  authors ; of  the  second  we  have  examples  in  the  hemor- 
rhagic purples  {purpura  hemorrhagica)  or  land-scurvy,  and  in  the 
genuine  sea-scurvy,  {scorbutus.) 

The  anatomical  characters  of  the  disease  consist  in  bright  red  or 
crimson  spots,  becoming  in  a day  or  two  purple  or  livid,  afterwards 
brown,  and  when  about  to  disappear,  assuming  a yellow  tint.  They 
are  occasionally  attended  with  long  livid  stripes  {vibices,  molopes), 
or  patches  {ecchymomata ;)  and  in  some  instances  the  cuticle  is 
raised  into  vesicles  or  large  purple  blebs,  {phlyctcence,)  containing 
bloody  or  purple  serous  fluid.  These  spots  consist  of  blood  or 
bloody  fluid,  effused  on  the  outer  surface  of  the  corion,  which  is 
soft  or  pulpy,  velvety,  and  reddish,  from  injection  of  its  vessels. 

§ 2.  Angiectasis. — Anastomotic  aneurism  is  frequent  in  the  corion, 
and  has  been  observed  by  J.  Bell,  Freer,  Travers,  and  Wardrop. 
Though  congenital,  it  must  not  be  confounded  with  the  ncevus  ma- 
ternus  or  birth-spot  {Venvie.,)  which  appears  to  consist  in  a peculiar 
original  malformation  of  the  corion.  A similar  congenital  defect 
is  the  white-spot  {leucosis.^  leuccethiopia,)  which  consists  in  the  ab- 
sence of  the  polished  vascular  surface  of  the  corion.  Occasionally 
it  takes  place  during  life,  and  in  minute  spots  is  observed  to  follow 
diseases  in  which  the  cuticular  surface  of  the  corion  has  been  de- 
stroyed by  ulceration. 

III.  Tumours. — § 1.  Meliheris  ; Cutaneous  or  Follicular  Wen. 
The  only  encysted  tumour  which  takes  place  in  the  skin  consists  in 
the  immoderate  enlargement  of  one  or  more  of  its  mucous  follicles, 
in  consequence  of  obstruction  of  the  excretory  duct.  When  from  any 
cause  this  takes  place,  the  sebaceous  matter,  which  in  the  healthy 
state  is  propelled  to  the  surface  and  removed,  accumulates  in  the 
interior  of  the  follicle,  which  is  thus  inordinately  distended,  till  by 
removing  tbe  obstruction  the  orifice  is  opened  and  the  inspissated 
matter  eliminated.  It  almost  invariably  again  accumulates,  unless 
care  be  taken  to  keep  the  excretory  duct  pervious, — an  object  which 
is  most  easily  and  certainly  attained  by  frequent  ablution.  This 
mode  of  explaining  the  origin  of  the  cutaneous  folliculated  tumour 

3 


SKIN. 


541 


was  understood  by  Morgagni,*  Haller,  Plenck,f  and  Monteggia,$ 
and  has  been  recently  revived  by  Sir  Astley  Cooper.  § 

§ 2.  Keloid  or  Cheloid  Tumour ; {Kells'^  Cheloidea.) — This  name 
has  been  applied  by  M.  Alibert  to  a peculiar  tumour  of  the  skin,  which 
bears  a resemblance  to  the  scar  or  discoloured,  irregular,  and  puck- 
ered cicatrix  of  a burn,  or  any  sore  which  has  healed  in  similar 
circumstances.  In  shape  it  is  oval  or  cylindrical,  generally  ele- 
vated above  the  level  of  the  skin.  The  colour  is  of  various  shades 
of  red,  sometimes  deep-red,  wine -red,  or  pink-coloured,  and  some- 
times only  flesh-red.  The  surface  is  irregular,  that  is,  elevated  into 
eminences,  with  intermediate  depressions ; and  often  it  is  seamed  or 
scarred.  In  general,  it  is  a little  firmer  than  the  surrounding  skin ; 
but  in  some  cases  it  presents  a sort  of  velvet-like  or  spongy  softness, 
which  allows  it  to  be  pressed.  From  the  margins  of  the  tumour 
occasionally  proceed  processes  like  the  feet  of  an  animal ; and  this 
circumstance,  with  its  irregular  appearance  in  general,  has  been 
supposed  to  be  the  reason,  why  it  is  occasionally  called  the  cheloid 
or  crab-like  tumour. 

The  keloid  tumour  may  consist  of  one,  two,  or  three  portions, 
the  lateral  margins  of  which  are  deeply  implanted  in  the  skin.  The 
surface  is  hard  and  in  general  resisting,  communicating  a sensation 
quite  diflerent  from  that  of  the  sound  skin.  It  is  void  of  pulsation, 
and  in  this  respect  difiers  fi’om  cutaneous  ncBvus. 

The  origin  of  this  disease,  and  the  causes  on  which  its  formation 
depends,  are  not  well  known.  It  is  rarely  congenital.  When  it 
first  appears,  it  is  small,  but  is  liable  to  enlarge  in  extent.  It  pro- 
ceeds, however,  very  slowly  ; and  months  or  years  may  elapse  be- 

* Adversaria  Anatomica. 

t “ Sedes  meliceridis,”  says  Plenck,  “ in  glandula  subcutanea  esse  videtur.  Quic- 
quid  ergo  porum  excretorium  glandulae  subcutanese  obdurat,  contentum  succum  in- 
spissat,  vel  ejus  absorptionem  impedit,  meliceridem  producere  valet.”  Systema  Tumo- 
rum,  Cl.  vii.  p.  153.  Viennae,  1767. 

J Istituzione  Chirurgiche,  Volume  ii.  § Surgical  Essays,  Part  2. 

II  It  is  quite  uncertain  whether  this  term  should  be  written  Cheloid  or  Keloid.  M. 
Alibert,  to  whose  neological  talents  we  are  indebted  for  the  term,  gives  the  followin'’- 
aynonymes.  Kelos  ; Cheloide  ; Cancroide  ; Tvherealea  durs  ; Cancelli ; Cancrama  ; 
Cancre  Mane  ; Le  Crabe.  If  the  name  be  derived  from  the  supposed  resemblance  to 
the  crab,  then  the  orthography  is  Cheloid.  On  the  other  hand,  the  term  Kelis,  Macula, 
a spot,  was  used  by  various  ancient  authors  to  signify  a foul  scar  or  ulcerated  mark  ; 
and  as  one  of  the  characters  of  the  keloid  tumour  is,  that  its  surface  and  margins 
sometimes  resemble  the  cicatrix  of  a burn,  this  may  be  with  most  propriety  regarded 
as  the  term  from  which  the  denomination  for  this  cutaneous  affection  should  be  taken. 


542 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


fore  much  change  in  its  size  or  appearance  can  be  detected.  In 
some  instances  its  formation  has  been  preceded  by  a burn  or  some 
ulcerative  process  of  the  skin  ; in  some  by  an  attack  of  small-pox ; 
in  other  instances,  it  is  said,  by  the  syphilitic  poison  affecting  the 
skin.  Most  commonly  it  occupies  the  sternal  region;  but  it  has 
been  observed  on  the  face  and  neck. 

As  to  the  nature  of  Kelis^  though  some  have  regarded  it  as  allied 
to  cancer,  this  seems  by  no  means  well  established.  The  tumour  j 
has  been  observed  to  remain  a long  time  on  the  body,  without 
showing  any  tendency  to  pass  into  cancerous  ulceration. 

§ 3.  Scirrho-carcinoma  of  the  skin  is  not  uncommon.  Though  it  || 
may  occur  in  any  part  of  the  cutaneous  covering,  it  commences  I 
most  frequently  in  situations  where  the  corion  is  delicate  and  thinly 
covered.  The  skin  of  the  face,  especially  of  the  eyelids,  prolabium,  i 
and  nose,  is  a frequent  seat  of  this  disorder ; and  next  to  these,  per-  ! 
haps,  are  to  be  placed  the  nipple  of  the  female  and  the  penis  of  the  i 

male,  the  corion  of  which  are  liable  to  be  affected  by  this  morbid  i 

structure.  The  scrotum  is  very  often  the  seat  of  that  peculiar  car- 
cinomatous destruction  occurring  in  the  persons  of  chimney  sweep- 
ers. In  all  these  cases  the  structure  is  much  the  same. 

It  may  appear  either  in  the  shape  of  tubercular  cancer,  or  in 
that  of  reticular  cancer.  In  the  former  case  small  hard  tubercles  i 
appear  to  be  formed  either  in  the  substance  of  the  corion,  or  in  the 
cutaneous  follicles.  These  coalesce  and  become  elevated,  forming 
a patch  of  skin,  red,  hard,  irregular,  hot,  and  the  seat  of  stinging 
pain.  After  some  time,  scales  are  formed  on  the  surface;  and 
along  with  or  after  these  slight  softening  takes  place.  The  scales 
and  crusts  are  ejected ; and  in  general  there  is  left  a hollow,  ul- 
cerating, non-granulating  surface,  secreting  serous  fluid,  and  gra- 
dually increasing  in  depth  and  extent.  Commonly  two  or  three  tu-  j 

bercles,  simultaneously  or  successively,  are  the  seat  of  this  process,  I 

so  that  the  part  presents  several  hollow  ulcers,  with  hard,  elevated 
edges  beginning  to  be  everted  or  already  everted. 

When  the  disease  assumes  the  reticular  shape  it  generally  affects 
a considerable  portion  of  skin  with  hard,  scirrhiform  swelling,  ir- 
regular in  surface,  and  tending,  after  some  time,  to  the  formation 
of  an  ulcerated  surface,  with  sanious  discharge,  and  hard,  elevated, 
everted  edges.  The  internal  structure  of  reticular  scirrhus  in  the 
skin  is  similar  to  that  structure  in  other  tissues. 

In  the  situation  of  the  corion  is  seen  a tough  firm  substance  of 


SKIN. 


543 


fibre -cartilaginous  structure,  the  fibrous  bands  being  generally  ar- 
ranged in  a waving  direction.  In  the  most  distinct  example  of  the 
disease  which  I examined  personally — a case  of  scirrho-carcinoma- 
tous  degeneration  of  the  whole  skin  of  the  penis,  these  fibrous  bands 
were  disposed  transversely  to  the  long  direction  of  the  part,  and  ap- 
peared to  consist  of  a fibro-cartilagiuous  long  band  folded  repeat- 
edly on  itself. 

IV.  Reproduction. — The  reparation  of  the  corion  when  destroyed 
has  been  maintained  by  many  authors.  Notwithstanding  their  as- 
sertions, however,  this  membrane  is  never,  after  its  substance  has 
been  injured,  restored  to  its  original  state.  The  breach  is  filled  up 
by  firm  cellular  tissue,  the  upper  surface  of  which  never  acquires 
the  organization  of  the  outer  surface  of  the  corion.  It  is  neverthe- 
less capable  of  furnishing  cuticle  by  which  this  new  corion  is  co- 
vered. These  facts  may  be  verified  in  the  cicatrization  of  burns 
and  other  injuries  in  which  the  corion  has  been  destroyed.* 

V.  Parasitical  Animals. — By  these  the  skins  both  of  animals  and 
the  human  race  are  liable  to  be  infested.  One  of  these  proper  to 
the  human  race,  (Demodex  Folliculorum)  has  been  already  noticed 
when  speaking  of  acne.  Besides  these  there  are  others  more 
easily  recognized,  especially  the  several  species  of  Pediculi ; the 
Ped.  Capitis ; the  Ped.  Corporis ; and  the  Ped.  Pubis,  or  3fo7'~ 
piones.  These  are  well  known,  and  require  no  notice  here.  Of 
one  parasitical  animal,  however,  the  existence  has  been  so  much 
contested  for  two  centuries,  that  it  was  alternately  admitted  and 
denied,  until,  by  the  aid  of  the  microscope,  its  existence  and  nature 
were  placed  in  1833  beyond  the  reach  of  doubt.  I refer  to  the 
itch  insect,  (the  Sarkoptes  scabiei).  A rapid  notice  of  the  discovery 
and  recognition  of  this  animal  is  all  that  can  be  admitted  in  these 
pages. 

For  several  centuries  the  inhabitants  of  tbe  south  of  Europe  re- 
cognized the  existence  of  an  insect  in  itch,  and  were  in  the  habit  of 
extracting  and  destroying  it.  In  the  12th  century  it  is  mentioned 
by  Abenzohr ; and  in  the  15th  and  16th  centuries  moi’e  or  less 
fully  by  Ingrassias,  Gabucinus,  and  Laurence  Joubert,  each  of 
whom  agreed  in  ascribing  to  the  movements  and  ravages  of  this 
animal  beneath  or  within  the  skin  the  fierce  itching  of  scabies. 

* Ottonis  Huhn  Commentatio  de  Regeneratione,  &c.  1787.  P.  23,  &c.  Andre® 
J.  G.  Murray,  Commentatio  de  Redintegratione,  1787.  P.  50.  A Dissertation  on 
the  Process  of  Nature  in  the  filling  up  of  cavities,  &c.  By  James  hloore.  Member 
&c.  London,  1789.  Sect.  ii.  p.  54,  &c. 


544 


GENERAL  AND  PATHOLOGICAL  ANATOMT. 


These  facts,  which  were  known  to  the  industrious  Thomas  Mouf  ■ 
fet,  are  confirmed  in  1 634  by  the  testimony  of  his  own  observation  ;* 
and  about  the  same  time,  Hauptmann  and  HafenreuflPer  noticed  the 
existence  of  the  insect.  The  fact,  nevertheless,  appears  by  many 
to  have  been  received  with  scepticism  or  positively  denied ; and 
even  in  1683,  when  Bonomo  addressed  to  Redi  a letter  on  the 
existence  of  the  insect  of  the  itch,  it  was  supposed,  to  be  one  of 
those  examples  of  credulity  which  foreign  naturalists  occasionally  ex- 
hibit.! Bonomo,  nevertheless,  had  described  the  animal  from  nature; 
and  in  1703  his  description  was  communicated  to  the  Royal  Society, 
by  Mead,!  and  afterwards  by  Baker  and  Schiebe,  in  such  a manner 
that  showed  that  the  latter  two  had  ascertained  the  existence  of  the 
animal,  and  examined  it  by  tbe  microscope. 

The  authority  of  Bonomo  prevailed  with  various  foreign  natu- 
ralists ; and  Linnaeus,  who  admitted  the  existence  of  the  insect  as 
a species  of  Acarus  or  mite,  adopted  the  description  of  the  Italian 
naturalist.  II  Bonomo,  however,  had  committed  an  error  in  consider- 
ing the  itch  insect  as  similar  to  the  common  mite  ; and  this  was  rec- 
tified by  De  Geer,  who  in  1778  both  established  the  existence  of  the 


* “ S3Tones  have  no  certain  form  ; only  they  are  round.  Our  eye  can  scarcely  dis- 
cern them  ; they  are  so  small  that  Epicurus  said  it  was  not  made  of  atoms,  but  was 
an  atom  itself.  It  dwells  so  under  the  skin,  that  when  it  makes  its  mines,  it  will  cause 
a great  itching,  especially  in  the  hands  and  other  parts  affected  with  them,  and  held 
to  the  fire.  If  you  pull  it  out  with  a needle,  and  lay  it  on  your  nail,  you  shall  see  it 
move  in  the  sun,  that  helps  its  motion ; crack  it  with  the  other  nail,  it  will  crack  with 
a noise  ; and  a watery  venom  comes  forth  ; it  is  of  a white  colour,  except  the  head; 
if  you  look  nearer,  it  is  blackish,  or  from  black  it  is  something  reddish.  It  is  a wonder 
how  so  small  a creature  that  creeps  with  no  feet,  as  it  were,  can  make  such  long  fur- 
rows under  the  skin.  This  we  must  observe,  by  the  way,  that  these  syrones  do  not 
dwell  in  tbe  pimples  themselves,  but  hard  by.  For  it  is  their  property  not  to  remove 
far  from  the  watery  humour,  collected  in  the  little  bladder  or  pimple,  and  where  that 
is  wasted,  or  dried  up,  they  all  die  shortly  after.”  Insectorum  sive  Minimomm  Ani- 
malium  Theatrum,  olim  ab  Wottono  Gesnero,  et  Pennio  inchoatum.  Folio.  London. 
1634.  The  Theatre  of  Insects  or  Lesser  Living  Creatures.  By  Thomas  Mouffet, 
Doctor  in  Physick.  London,  1658.  Folio,  Chapter  xxiv.  p.  1094  of  Topsel. 

-f-  G.  C.  Bonomo  Osservazioni  intorno  a pellicelli  del  corpo  umano.  Florenza, 
1683. 

G.  C.  Bonomo  Obs.  circa  humani  corporis  teredinem.  Ephem  Nat.  Cur.  Dec.  TI. 
Ann.  X.  App.  p.  33. 

J An  Abstract  of  part  of  a Letter  from  Dr  Bonomo  to  Signor  Redi,  containing  some 
Observations  concerning  the  Worms  of  Human  Bodies.  By  Richard  Mead,  M.  D. 
Phil.  Trans,  for  1703,  No.  283,  p.  1296.  Vol.  XXIII.  London,  1704. 

II  Linnaeus  Exanthemata  Viva.  Amoenitatis  Academicae,  V.  n.  82,  et  VIII.  p.  73 
and  283. 


SKIN. 


545 


animal,  and  specified  the  diflPerential  characters  between  it  and  the 
vegetable  mite.* * * §  In  1786  and  afterwards  in  1791,  Wichmann,  a 
physician  at  Hanover,  published  a work  on  the  itch  insectt ; and 
his  descriptions  were  verified  by  Goeze. 

From  the  testimony  of  these  observers  it  might  have  been  ex- 
pected that  the  existence  of  the  itch  insect  was  recognized  as  esta- 
blished. English  dermatologists  were,  however,  sceptical ; and  they 
were  supported  on  the  continent  by  the  authority  of  Sagar,  Bal- 
dinger,  Jonasf,  Volkraann,§  Harttgann,||  Weise,  Alexander,  and 
Mieg;  and  this  feeling  was  increased  by  Joseph  Adams,  who,  while 
he  showed  that  a particular  kind  of  insect(oucao)  burrows  in  the  skin 
in  the  natives  of  Madeira,  maintained  that,  as  this  was  not  the  itch 
insect,  no  animal  of  that  kind  existed.  This  scepticism,  both  among 
English  and  French  physicians,  was  much  increased  by  the  pro- 
ceedings of  M.  Gales,  a pupil  of  Alibert,  who,  in  1812,  presented 
as  the  genuine  itch  entozoon,  figures  and  bodies  of  the  common 
cheese  mite. 

At  length,  however,  in  1831,  M.  Raspail  having  discovered  in 
the  itch  pustules  of  the  horse,  an  insect  similar  to  that  delineated 
hy  De  Geer,  was  satisfied  that  it  was  possible  to  discover  a similar 
parasite  in  the  itch  eruption  of  the  human  race.  It  was,  however, 
still  the  entomologists  of  the  south  of  Europe  who  were  to  deter- 
mine this  as  an  unquestioned  fact  M.  Renucci,  a student  of  me- 
dicine from  Corsica,  surprised  to  find  the  existence  of  the  insect 
questioned,  showed  it  to  several  observers,  among  others  to  hi. 
Raspail ; and  it  is  solely  to  the  labours  of  the  latter  that  we  are  in- 
debted for  a correct  description  of  this  long  doubted  and  doubtful 
animal.1T 

The  itch  insect  is  white  at  first  sight,  but  with  some  reddish- 
brown  points  on  its  circumference.  It  may  be  seen  without  a 

* De  Geer  Memoixes  pour  servir  a I’histoire  des  Insectes.  Stockholm,  1778.  4to, 
T.  VII.  p.  92,  PL  5: 

t Jo.  Ernest  Wichmann  .ffitiologie  von  der  Kraze.  Hanover,  1786. 

J Jonas  Dissert.  Dubia  circa  ^tiologiam  Wichmannianam  Scabiei.  Halae,  1787. 

§ Volkmann  Diss.  sistens  quaestiones  medicas  super  Wichmanni  jEtiologia  Scabiei. 
Francofurti  ad  Viadr,  1787. 

II  Hartmann  Dissert.  Quaestiones  super  Wichmanni  aetiologia  Scabiei.  Fr.,  1789. 

U Bulletin  General  de  Therapeutique,  Septembre  1834. 

Raspail  Memoire  Comparatif  sur  I’histoire  naturelle  de  llnsecte  de  la  Gale.  Fig. 
8vo.  Paris,  1834. 


M m 


54G 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


magnifying  glass  moving  on  a coloured  surface,  especially  if  dark. 
It  is  about  xiola  parts  of  one  inch  in  diameter.  With  one  glass, 
the  feet  may  be  numbered,  the  mouth  distinguished,  and  all  the  other 
details  of  outline  recognized.  The  head  and  fore  feet  are  capable  of 
being  concealed  under  the  body  by  incurvation  downwards ; and  in 
this  attitude  these  five  members  seem  withdrawn  within  coverings. 
The  posterior  portion  of  the  body  placed  in  the  same  position  pre- 
sents eight  setcB  or  hairs,  gradually  decreasing  in  size,  till  they  ap- 
proach the  vent.  Four  of  them  belong  to  the  hind  feet;  and  of 
the  other  four,  two  are  inserted  on  each  side  of  the  vent. 

When  examined  lengthwise  hy  the  microscope,  the  animal  ap- 
pears flattened  ; and  in  the  transparent  places  it  presents  parallel 
curved  striae,  which  give  it  the  appearance  of  the  shell  of  a fish 
viewed  by  the  same  magnifying  power.  These  strics  cover  the 
whole  surface  of  the  body  of  the  insect,  forming  a large  cellular 
network,  the  cellulcB  of  which  are  linear  and  hollow,  the  interstitial 
partitions  relieved  and  prominent.  This  network  strongly  re^sts 
cutting  instruments,  so  that  it  is  difficult  to  kill  the  insect  with  the 
point  of  a needle  while  extracting  it. 

When  placed  on  the  back,  so  as  to  examine  the  anterior  or  infe- 
rior surface,  the  organization  of  this  insect  appears  greatly  more 
complicated.  The  head  and  the  four  anterior  feet  are  implanted 
in  an  equal  number  of  cases,  not  dissimilar  to  incomplete  ehjtrce. 
The  head  is  simple  and  curved  downwards  by  the  snout  or  probo- 
scis, or  sucker.  Placed  in  acetic  acid,  two  transparent  vesicles  come 
into  view,  which  might  be  taken  for  eyes.  The  articulations  of  the 
legs  require  long  observation  to  be  quite  visible.  Each  of  these 
articulations  is  covered  by  hairs,  of  which  those  only  on  the  sides 
are  visible.  The  last  joint  is  covered  with  short  prickles,  and  armed 
beneath  with  a stiff  hair,  which  is  terminated  beneath  by  a flexible 
cavity  capable  of  producing  a vacuum,  like  the  soft  glutinous  pads 
of  certain  animals  much  higher  in  the  scale,  such  as  the  tree-frog. 
To  these  pads,  which  enable  the  animal  to  fix  itself  in  any  position, 
M.  Raspail  applies  the  denomination  of  ambulacra. 

There  are  four  posterior  legs,  which  are  smaller  and  shorter,  and 
less  easily  distinguished  than  the  anterior  legs.  They  are  so  small 
and  slender  that  by  De  Geer  they  were  mistaken  for  hairs  or  setcB. 
They  have  the  same  organization  and  the  same  locomotive  apparatus 

as  the  anterior  legs,  excepting  the  part  called  by  Raspail  ambulacrum., 

3 


SKIN. 


547 


instead  of  which  are  very  long  hairs.  The  anterior  or  abdominal 
surface  of  the  insect  is  striated  as  well  as  its  dorsal  surface. 

This  insect  is  not  an  acarus,  as  imagined  by  Linnaeus  and  other 
entomologists.  In  consequence  of  the  differential  characters,  it  has 
been  referred  by  Raspail  to  a separate  genus  under  the  name  of 
Sarhoptes,  or  Flesh-roaster,  caro  ; Oirraw,  torreo.) 

It  has  now  been  seen  by  so  many  observers,  both  in  France  and 
this  country,  that  there  is  no  chance  that  its  existence  can  again  be 
questioned.  It  works  its  way  beneath  the  cuticle  by  making  bur- 
rows or  paths  in  the  vascular  layer  of  the  skin. 

The  nails,  like  the  cuticle,  may  be  diseased  in  consequence  of  a 
morbid  state  of  the  corial  surface  and  vessels  by  which  they  are 
nourished.  In  one  or  two  instances  of  strumous  children,  I have 
seen  them  fissured  into  several  longitudinal  portions,  much  thick- 
ened, and  indurated  like  horn,  and  incurvated.  In  others  of  the 
fingers  of  the  same  individuals,  they  were  small  and  imperfectly  de- 
veloped ; and  in  some  their  place  was  supplied  by  a small  portion 
of  thick  horny  cuticle.  Similar  changes  are  sometimes  induced  by 
disease  or  by  injury. 

Of  the  hairs,  the  most  extraordinary  morbid  state  is  the  Polish 
plait  (^plica  Polonica ,-)  so  named  from  being  endemial  in  Poland, 
Lithuania,  Hungary,  and  Transylvania,  from  the  source  of  the  Vis- 
tula to  the  Carpathian  mountains.  It  occurs  also  in  Prussia,  Rus- 
sia, Switzerland,  and  in  some  parts  of  the  Low  Countries.  It  is 
impossible  to  doubt  that  this  abnormal  condition  of  the  hairs  depends 
on  disease  taking  place  in  their  bulbs  or  nutritious  sacs.  This  is 
proved  by  the  state  of  the  skin  from  which  the  diseased  hair  grows, 
and  by  the  unctuous,  viscid,  and  blood-coloured  fiuid  which  the 
hairs  in  this  state  contain.  We  nevertheless  possess  no  very  pre- 
cise information  on  the  nature  of  this  diseased  state  of  the  capillary 
bulbs ; and  in  the  absence  of  exact  facts  I abstain  from  offering 
conjectures. 

The  piliparous  sacs  lose  their  energy  under  certain  morbid  states 
of  the  system ; for  instance,  fever,  pulmonary  consumption,  and  the 
constitutional  symptoms  of  lues.  The  hairs  then  drop  out ; and  if 
at  this  time  the  bulbs  be  examined,  the  sacs  are  found  to  contain, 
according  to  Bichat,  at  least  in  persons  who  have  passed  through 
fever,  the  rudiment  of  new  hairs.  The  shedding  of  the  hairs,  which 
takes  place  in  the  decline  of  life,  and  the  period  of  which  varies  re- 


548 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


raarkably  in  different  individuals,  Bichat  represents  as  depending 
on  a total  death  of  the  piliparous  sacs. 

Accidental  and  abnormal  developement  of  hairs  is  not  uncom- 
mon. In  the  skin  this  appears  in  the  shape  of  hairy  moles  and 
similar  congenital  marks.*  Their  occurrence  in  the  stomach,  in- 
testines, and  bladder,  as  noticed  by  a variety  of  authors,  is  also  to 
be  regarded  as  abnormal.  Lastly,  the  accidental  developement  of 
hairs  is  observed  in  encysted  tumours,  especially  those  of  the  ovaries, 
in  which  masses  or  balls  of  hair  mixed  with  fat,  oleaginous,  or  adi- 
pocirous  matter,  have  been  frequently  found. f On  the  mode  in 
which  these  hairs  are  formed  nothing  satisfactory  is  known. J 


CHAPTER  II. 

Section  I. 

MUCOUS  MEMBRANE,  VILLOUS  MEMBRANE. — Membrana  mucosa, 
M.  mucipara,  M.  villosa, — Tissu  Muqueux,  Bichat. 

The  organic  tissue  or  membrane,  to  which  the  name  of  mucous 
or  villous  has  been  applied,  consists  of  two  great  divisions,  the  gas- 
tro-pulmonary,  and  genito-urinary. 

A.  The  first  or  gastro-pulmonary  mucous  surface  comprehends 
that  membranous  surface  which  commences  at  the  various  orifices 
of  the  face,  at  which  it  is  contiguous  with  the  skin  ; and  is  continu- 
ed through  the  lacrymal  and  nasal  passages,  and  even  the  Eusta- 
chian tube,  by  the  larynx  on  the  one  hand  to  the  windpipe  and 
bronchial  membrane,  and  by  the  oesophagus  on  the  other  through 
the  entire  tract  of  the  alimentary  canal,  at  the  opposite  extremity 
of  which,  it  is  again  identified  with  the  skin. 

B.  The  distribution  of  the  second  division,  or  the  genito-urinary 
mucous  membrane,  is  slightly  varied  according  to  the  differences 
of  sex.  In  the  male  it  is  connected  with  the  skin  at  the  orifice  of 
the  urethra,  from  which  it  proceeds  inwards  toward  the  bladder ; 

* Haller,  Elementa  Physiologia:,  Lib.  XII.  Sect  1.  § XVII. 

Bichat,  Tom.  IV.  p.  828. 

J Meckel,  Joiun.  Compl.  T.  IV.  and  Bricheteau,  Journ.  Compl.  T.  XV. 


MUCOUS  MEMBRANE. 


549 


sending  previously  small  prolongations  through  ducts  on  each  side 
of  the  oeru  montanum,  from  which  it  is  believed  to  be  continued 
through  the  vasa  deferentia,  to  the  vasa  efferentia  of  the  testicle. 
Continued  over  the  inner  surface  of  the  urinary  bladder,  it  is  pro- 
longed through  the  ureters  to  the  pelvis  and  infundibula  of  the 
kidney.  In  the  female,  besides  passing  in  this  direction,  it  ascends 
into  the  womb,  and  passes  through  the  Fallopian  or  uterine  tubes> 
at  the  upper  extremity  of  which  it  terminates  in  an  abrupt  opening 
into  the  sac  of  the  peritonaeum, — the  only  instance  in  the  whole 
body  in  which  a mucous  and  serous  surface  communicate  freely 
and  directly. 

These  two  orders  of  membranous  tissue  have  each  two  surfaces, 
an  attached  or  adherent,  and  a free  one.  The  adherent  surface  is 
attached,  Is?,  to  muscles,  as  in  the  tongue  ; most  of  the  mouth  and 
fauces,  oesophagus,  and  whole  alimentary  canal,  and  the  bladder ; 
2c?,  to  fibrous  membranes,  as  in  the  nasal  cavities  and  part  of  the 
larynx,  in  which  it  is  attached  to  periosteum  or  perichondrium,  the 
palate,  ureter,  and  pelvis  of  the  kidney  ; 3c?,  to  fibro-cartilages,  as 
in  the  windpipe,  {trachea,')  and  bronchial  tubes. 

The  free  surface  is  not  uniform  or  similar  throughout.  The  ap- 
pearance of  the  pituitary  or  Schneiderian  membrane  is  different 
from  that  of  the  stomach  or  intestines  ; the  surface  of  the  tongue 
and  mouth  is  different  from  that  of  the  trachea;  and  the  free  sur- 
face of  the  urethra  is  unlike  that  of  the  bladder.  These  variations 
depend  on  difference  of  structure,  and  are  connected  with  a diffe- 
rence in  properties ; yet  anatomists  have  improperly  applied  to  the 
whole  what  was  peculiar  to  certain  parts  only,  and  have  thus  creat- 
ed a system,  in  which  some  truth  is  blended  with  much  misrepre- 
sentation. 

Mucous  membrane  consists,  like  skin,  of  a corion  or  derma,  and 
an  epidermis  or  cuticle. 

The  mucous  corion  is  a firm  dense  gray  substance,  which  forms 
the  ground-work  of  the  membrane  in  most  regions  of  the  body,  but 
which  is  evidently  represented  by  the  fibrous  system,  e.  g.  the  pe- 
riosteum or  perichondrium,  in  some  other  situations.  It  is  most 
distinctly  seen  in  the  mouth  and  throat,  and  in  various  parts  of  the 
alimentary  canal.  In  the  first  situation  it  is  more  vascular,  less 
gray  and  dense  than  in  the  intestinal  mucous  membrane. 

It  possesses  two  surfaces,  an  inner,  adherent  to  the  submucous 
filamentous  tissue,  and  an  outer  or  proper  mucous  surface.  In  the 


550 


GENERAL  AND  EATHOLOGICAL  ANATOJIY. 


stomach,  the  mucous  corion  is  in  the  form  of  a soft  but  firm  mem- 
branous substance,  about  one-sixth  or  one-eighth  of  one  line  thick, 
tough,  of  a dun-gray  or  fawn  colour,  (intermediate  between  Sienna- 
yellow  and  ochre-yellow,  Syme,)  slightly  translucent,  and  sinking 
in  water.  The  attached  or  inner  surface  is  flocculent  and  tomen- 
tose,  and  a shade  lighter  than  the  outer,  which  presents  a sort  of 
shag  or  velvet,  consisting  of  very  minute  piles.  This,  when  exa- 
mined by  a good  lens  at  oblique  light,  appears  to  consist  of  an  in- 
finite number  of  very  minute  roundish  bodies  closely  set,  but  sepa- 
rated by  equally  minute  linear  pits,  and  occasionally  circular  de- 
pressions. In  the  ileum  it  presents  much  the  same  characters  ; but 
the  minute  bodies  of  its  shaggy  surface  are  still  larger  and  more 
distinct,  and  may  be  seen  by  the  naked  eye.  In  the  windpipe, 
again,  it  is  rather  thinner  and  lighter  coloured  ; and  while  its  outer 
surface  presents  numerous  minute  pores,  it  is  much  smoother  than 
in  the  alimentary  canal,  and  entirely  destitute  of  those  minute  bodies 
seen  in  the  latter.  It  nowhere  presents  any  appearance  of  fibres. 

The  mucous  corion  rests  on  a layer  of  filamentous  tissue,  pretty 
firm  and  dense,  and  of  a bluish  white  colour,— a character  by  which 
it  is  easily  distinguished  from  the  soft  fawn-coloured  mucous  mem- 
brane. This  submucous  filamentous  tissue  is  what  is  erroneously 
termed  the  nervous  coat  by  Ruysch,  Albinus,  and  some  of  the  older 
anatomists.  In  certain  parts  the  mucous  corion  is  covered  by  a 
thin  membrane,  which  has  been  named  the  epidermis  or  cuticle. 

It  is  exceedingly  difficult  to  demonstrate  this  membrane  dis- 
tinctly. It  is  very  thin,  quite  transparent,  and  is  perhaps  most 
easily  shown  by  boiling  or  scalding  a portion  of  mucous  membrane, 
and  then  peeling  off  with  care  the  outer  pellicle.  This  experiment 
succeeds  best  in  the  mucous  membrane  of  the  mouth  and  palate, 
in  which,  therefore,  the  existence  of  mucous  epidermis  cannot  be 
doubted.  In  cases  of  death  by  swallowing  boiling  water,  the  epider- 
mis is  raised  in  the  form  of  vesications  on  the  base  of  the  tongue,  on 
the  epiglottis,  and  even  sometimes  at  the  arytenoid  membrane ; and 
I have  seen  the  epidermis  of  the  epiglottis  forming  vesications  in  con- 
sequence of  the  deglutition  of  sulphuric  acid.  The  observations 
of  Wepfer,  Haller,  and  Nicholls,  and  especially  of  Bleuland,*  ai-e 
sufficient  to  prove  its  existence  in  the  oesophagus.  Bichat  admits 
that,  though  it  can  be  demonstrated  at  the  cutaneous  junctions  of 

* Jani  Bleuland,  M.  D.  Observatioiies  Anatomico-Medicae  de  Sana  et  morbosa  ceso- 
phagi  structura.  Lug.  Bat.  1785. 


MUCOUS  MEMBRANE. 


551 


the  mucous  surfaces,  it  can  no  longer  be  shown  to  exist  in  the 
stomach,  intestines,  bladder,  &c.  Bedard  renders  this  conclusion 
precise,  by  showing  experimentally  that  mucous  epidermis  cannot 
be  traced  in  the  oesophagus  beyond  the  cardia ; in  the  genito- urinary 
system  beyond  the  neck  of  the  womb,  and  that  of  the  bladder. 

The  termination  of  the  epidermis  at  the  lower  end  or  cardiac 
junction  of  the  oesophagus  is  very  remarkable.  It  is  seen  by  the 
eye,  but  more  clearly  by  the  aid  of  a good  glass.  It  is  observed 
to  form  or  send  out  long  triangular  processes,  the  base  connected 
with  the  oesophageal  epidermis,  the  apices  free,  leaving  also  between 
them  triangular  spaces.  The  length  of  these  processes  varies  from 
one-third  of  an  inch  to  half  an  inch  and  two-thirds  of  an  inch. 
Their  number  is  also  variable,  and  sometimes  in  the  same  subject 
they  differ  in  size.  They  are  rendered  very  distinct  by  immersing 
the  oesophagus  in  boiling  water,  which  renders  them  opake,  or  in 
nitric  acid,  which  imparts  to  them  an  orange-yellow  tinge,  leaving 
the  intermediate  and  adjoining  mucous  corion  little  changed. 

In  the  uterus  it  is  quite  easy  to  see  that  the  epidermis  does  not 
advance  beyond  the  upper  extremity  of  the  vagina.  The  uterine 
mucous  membrane  presents  no  appearance  of  epidermis. 

The  structnre  of  mncous  membrane  varies  in  every  situation  and 
in  every  organ ; and  as  the  mucous  membrane  of  the  alimentary 
canal  has  been  most  frequently  examined,  on  that,  accordingly, 
the  greatest  amonnt  of  information  has  been  communicated. 

This  division  of  the  mucous  system  presents  most  distinctly  and 
in  greatest  perfection  three  sets  of  objects,  the  true  structure  of 
which  it  is  believed  highly  important  to  understand  arigbt. 

These  are  the  tubulo-cellular  structure  of  the  stomach,  the  villi.^ 
and  the  muciparous  follicles  or  glands. 

The  mucous  membrane  of  the  stomach,  which  first  deserves  atten- 
tion, is  not  villous,  properly  speaking,  so  much  as  cellular.  Hewson 
had  early  observed,  that  at  the  upper  part  of  the  stomach,  the  vil- 
lous coat  appears  in  a miscroscope  like  a honey-comb,  or  like  the 
second  stomach  of  ruminating  animals  in  miniature,  that  is,  full  of 
small  cells  which  have  thin  membranous  partitions.  Towards  the 
pylorus  these  partitions  are  lengthened  so  as  to  approach  to  the 
shape  of  the  villi  in  the  jejunum. 

These  cells  Sir  E.  Home  represents  as  found  in  the  form  of 
a honey-comb  in  the  upper  end  of  the  stomach,  and  to  be  of 
greatest  depth  in  this  region,  though  seen  over  the  whole  cardiac 


552 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


portion,  but  so  faintly  that  a high  magnifying  power  is  required 
to  render  them  visible.  In  the  pyloric  portion  the  same  cellular 
appearance  continues ; but  here  and  there  are  small  clusters,  the 
sides  of  which  rise  above  the  surface,  giving  the  appearance  of 
foliated  membranes. 

These  cells  are,  according  to  Dr  Boyd,  about  y’^gth  of  one  inch 
in  diameter  near  the  cardia.  Not  half  an  inch  from  the  cardia, 
however,  these  large  cells  give  place  to  small  regular  cells  which 
characterize  the  whole  internal  surface  of  the  organ.  When  the 
mucous  membrane  is  extended,  they  appear  regular  both  in  shape 
and  size,  varying  from  ^ggth  to  jggth  part  of  one  inch  in  diameter, 
being  smaller  in  the  young  than  in  the  adult.  Near  the  pylurus^ 
again,  they  are  enlarged,  being  about  iggth  of  one  inch  in  diameter. 
The  floor  of  each  cell  appears  perforated  by  numerous  circular 
openings,  as  if  a number  of  tubes  opened  on  it;  and  on  making  a 
vertical  section  of  the  mucous  membrane,  it  is  seen  to  be  composed 
of  stricB  or  fibres  running  perpendicularly  from  the  free  surface  of 
the  membrane  to  the  cellular  coat  beneath. 

These  stricB  or  fibres  are  known  to  be  small  tubes  lying  parallel 
to  each  other.  These  tubes  are  longest,  and  are  most  distinctly  seen 
near  the  pylorus^  and  indeed  all  over  the  organ.  At  the  cardia 
they  are  short,  little  more  than  simple  rings,  lying  close  to  each 
other.  They  are  about  P^^t  of  one  inch  in  diameter,  appear 

to  have  no  immediate  connection  with  the  cells  into  which  they  gene- 
rally open,  and  are  supposed  to  be  subservient  to  a different  func- 
tion.* There  is  strong  reason  to  believe,  nevertheless,  that  these 
tubes  are  concerned  in  some  mode  in  the  secretion  of  gastric  ffuid. 

In  the  human  stomach,  glands  or  follicles  are  found  mostly  at 
the  pylorus.  In  other  regions  they  are,  in  the  state  of  health,  not 
very  distinct.  Indeed,  the  gastric  follicles  of  the  human  stomach 
are  always  in  the  healthy  state  indistinct.  A kind  of  minute  gland- 
like bodies  nevertheless  is  sometimes  perceptible  along  the  small 
arch. 

The  next  peculiarity  which  it  is  important  to  notice  is  the  exist- 
ence of  minute  piles  or  villosities  in  the  gastro-enterie  division. 
These  bodies  are  best  seen  by  detaching,  inverting,  and  inflating  a 
portion  of  ileum.  When  this  is  immersed  in  pure  water,  the  ob- 
server may  perceive,  by  means  of  its  refracting  power,  an  infinite 

■“  Essay  on  the  Structure  of  the  Mucous  Membrane  of  the  Human  Stomach,  by  Sprott 
Boyd,  M.  D.  Edinburgh  Medical  and  Surgical  Journal,  Vol.  XLVI.  p.  382.  Edin- 
brngh,  1836. 


4 


MUCOUS  MEMBRANE. 


553 


number  of  minute  prolongations,  which  are  made  to  wave  or  move 
gently  amidst  the  fluid ; hut  even  a very  powerful  magnifying  glass 
does  not  render  them  so  distinct,  as  to  determine  whether  they  are 
round  or  flattened,  whether  they  are  solid  or  hollow,  or  whether 
they  are  ohtuse  or  acuminated.  The  shape  and  structure  of  these 
villosities  are  indeed  imperfectly  known. 

These  piles,  die  zotten,)  though  seen  by  many  anatomists, 

were  first  examined  in  172Uby  Helvetius,  who  represents  them  as 
cylindrical  prominences  in  quadrupeds,  hut  conical  in  the  human 
subject.* * * §  Their  intimate  structure,  however,  Lieberkuhn  under- 
took first  by  microscopical  observation  to  demonstrate.  According 
to  this  observer,  each  villus  receives  a minute  branch  of  a lacteal, 
arterial  branches,  a vein,  and  a nerve ; and  in  each  the  lacteal 
branch  is  expanded  into  a minute  sac  or  h\B.ddiQv{ampullula,vesicula,) 
like  an  egg,  the  capacity  of  which  he  estimates  at  |th  of  a cubic 
line,  and  in  the  apex  of  which  may  be  seen  by  the  microscope  a 
minute  opening.f  Upon  this  sac  the  arterial  branches  are  ramified 
to  great  delicacy,  and  terminate  in  minute  veins,  which  then  unite 
into  one  trunk ; while  its  inner  surface  he  represents  as  spongy 
and  cellular.  The  space  between  the  villi^  which  do  not  touch 
each  other,  he  further  represents  to  be  occupied  by  the  open  ori- 
fices of  follicles,  ■ so  numerous  that  he  counted  eighty  of  them, 
where  were  eighteen  villi ; and  both,  he  asserts,  are  covered  by  a 
thin  but  tenacious  membrane  similar  to  epidermis. 

Hewson,  while  he  admits  in  each  villus  the  ramification  of  mi- 
nute arteries  and  veins,  denies  the  saccular  expansion,  and  infers 
that  the  lacteals  are  ramified  in  the  same  manner  as  the  blood-ves- 
sels, and  that  the  whole  constitute  a broad  flat  body,j  the  spongy 
appearance  of  which  he  ascribes  to  the  mutual  ramification  of  the 
latter.  With  this  in  general  Cruikshank  agrees  ;§  while  Sheldon, 
who  found  the  villi  not  only  round  and  cylindrical  as  Hewson,  but 
bulbous  as  Lieberkuhn,  and  even  sabre-shaped,  rather  confirms  the 
statements  of  that  anatomist.  ||  Mascagni  and  Soemmering  agree- 
ing in  the  general  fact  of  vascular  and  lacteal  structure,  seem  to 


* Mem.  de  I’Acad.  des  Sciences.  1721. 

-f-  J.  N.  Lieberkuhn,  M.  D.  &c.  Dissertatio  Anatomio-Physiologica  de  Fabrica  et  Ac- 
tione  villorum  Intestinomm  Tenuium  Hominis.  Lugduni  Batavorum,  1745.  4to  ; et 
cura  J.  Sheldon.  Londini,  1782,  § ii.  iii.  &c. 

J Experimental  Inquiries,  part  ii.  p.  175,  chapter  xii. 

§ The  Anatomy  of  the  Absorbing  Vessels,  Ao.'p.  58. 

II  The  History  of  the  Absorbent  System,  p.  36  and  37. 


554 


GENERAL  AND  rATHOLOGICAL  ANATOMY. 


represent  the  shape  of  the  villus  as  that  of  a mushroom,  consisting 
of  a stalk  and  a pileus. 

Some  of  these  discordant  statements  Hedwig  attempts  with  equal 
ingenuity  and  industry  to  reconcile.  The  difference  in  shape  he 
refers  to  differences  in  the  animals  examined ; and  in  one  class 
finds  them  cylindrical,  (c.  g.  in  man  and  the  horse ;)  in  another 
conical,  (the  dog ;)  in  a third  club-shaped,  (the  pheasant ;)  and  in 
a fourth  pointed  or  pyramidal,  (c.  g.  the  mouse.)  The  interior 
structure  he  also  represents  as  spongy  in  all  the  animals  which  he 
examined;  and  invariably  also  he  found  at  the  apex  the  orifice  of 
the  duct,  which,  after  the  example  of  Lieberkuhn,  he  conceives 
constitutes  the  ampullula* 

These  conclusions  are  not  exactly  confirmed  by  the  researches 
of  Rudolphi,  who  examined  the  villi  in  man  and  a considerable 
number  of  animals.  This  anatomist  never  found  the  orifice  seen 
by  Hedwig,  notwithstanding  every  care  taken  to  perceive  it.  He 
maintains  that  the  villi  are  not  alike  in  all  parts  of  the  intestinal 
canal  of  the  same  animal,  as  represented  by  Hedwig,  but  may  be 
cylindrical  in  one  part,  club-shaped  in  another,  and  acuminated  in 
a third.  Admitting  their  vascular  structure,  which  he  thinks  may 
be  demonstrated,  he  regards  the  ampullular  expansion  as  doubtful, 
and  denies  its  cellular  arrangementf 

About  the  same  time  Bleuland,  who  had  previously  examined 
the  intestinal  mucous  membrane,  after  successful  injection  of  its 
capillaries,  undertook  to  revive  the  leading  circumstances  of  the  de- 
scription of  Lieberkuhn.  By  examining  microscopically  well-in- 
jected portions  of  intestine,  he  shows  that  the  villi  are  composed  of 
a system  of  very  minute  arterial  and  venous  capillaries,  enclosing 
a lacteal  which  constitutes  the  ampulla,  and  in  the  interior  of  which 
a certain  order  of  these  capillaries  terminates.  He  also  revives  the 
statement  of  the  absoi’bing  orifice  at  the  extremity  of  each  villus.X 
The  rest  of  the  observations  of  this  author  pertain  rather  to  the  dis- 
tribution of  the  minute  vessels,  and  shall  be  more  particularly  no- 
ticed under  that  head. 

The  observations  of  Bedard  on  these  bodies  are  most  perspicu- 

* Disquisitio  Ampullularum  Lieberkuhnii  Physico-Microscopica.  Lipsiae,  1797.  4to. 

•j-  Einige  Beobachtungen  iiber  die  Dannzotten  von  D.  Karl  A.  Rudolphi.  in  Reil. 
Archiv.  iv.  b.  1797,  p-  63  and  340.  Und  Anatomische-Physiologische  Abhandlungen, 
Von  Kail  Asmund  Rudolphi,  Mil.  Acht  Kupfertafeln.  Berlin,  1802.  8vo.  III. 

X Jani  Bleuland,  M.  D.  &c.  Vasculorum,  in  Intestinorum  Tenuium  Tunicis,  &c. 
Descriptio  Iconibus  lllustrata.  Trajecti  ad  Rhenum,  1797. 


MUCOUS  MEMBIiANE. 


555 


ous.  According  to  this  anatomist  the  intestinal  villi  appear  neither 
conical,  nor  cylindrical,  nor  tubular,  nor  expanded  at  top,  as  de- 
scribed by  several  authors,  but  in  the  shape  of  leaflets  or  minute 
plates  so  closely  set  that  they  form  an  abundant  tufted  pile.  Their 
shape  varies  according  to  the  manner  in  which  they  are  examined, 
and  according  to  the  part.  Those  of  the  pyloric  half  of  the  sto- 
mach and  duodenum  are  broader  than  long,  and  form  minute  plates; 
those  of  jejunum  are  long  and  narrow,  constituting  piles;- at  the 
end  of  the  ileum  they  become  laminar ; and  in  the  colon  are  scarcely 
prominent.  They  are  semitranslucent ; their  surface  is  smooth; 
and  neither  openings  at  their  surface,  or  cavity,  or  their  interior, 
or  vascular  structure  can  be  recognized.* 

Follicles  and  Crypts. — In  most  mucous  membranes  are  found 
minute,  oval,  or  spheroidal  bodies,  slightly  elevated,  and  present- 
ing an  orifice  leading  to  a blind  or  shut  cavity.  As  they  are  be- 
lieved to  secrete  a fluid  analogous  to  or  identical  with  mucus,  they 
are  named  raucous  glands;  and  from  their  shape  and  situation  they 
are  also  denominated  follicles  (folliculi)  and  crypta.  Though 
found  in  all  the  mucous  membranes  in  more  or  less  abundance, 
they  have  been  most  frequently  examined  in  those  of  the  alimen- 
tary canal,  where  they  were  first  accurately  described  by  Peyer 
and  Brunner.  ( Glandules  Peyeriancs.X)  In  this  situation  they  are 
situate  in  the  substance  of  the  mucous  corion.  Their  structure,  so 
far  as  it  can  be  examined,  is  simple.  The  orifice  leads  into  a sac- 
cular cavity,  the  surface  of  which  is  smooth  and  uniform,  and  ap- 
pears to  secrete  the  fluid  which  oozes  from  them.  This  membranous 
sac  appears  to  be  lodged  in  a reddish-coloured,  dense,  abnormal  mat- 
ter, which  is  probably  filamentous  tissue  enveloping  minute  blood- 
vessels ; but  of  tbe  minute  structure  of  which  nothing  is  accurately 
known.  In  the  state  of  health  these  bodies  are  so  minute  that  it 
is  very  difficult  to  recognize  them.  I have  seen  them,  neverthe- 
less, in  the  tracheo-bronchial  membrane  by  the  eye  and  by  a lens. 
When  the  membranes  are  inflamed  they  become  larger  and  more 
distinct.  In  the  bladder,  the  womb,  the  gall-bladder,  and  the  se- 
minal vesicles,  they  are  not  distinctly  seen,  and  cannot  be  satisfac- 
torily demonstrated.  It  is  unnecessary,  however,  to  follow  the  ex- 

* Anatomie  Generale,  chap.  iii.  sect.  2de,  p.  253. 

•]-  Joannis  Conracli  Peyeri  Pareiga  Anatomica  et  Medica  Septem,  Ratione  ac  Ex- 
perientia^parentibus  concepta  et  edita.  Genevas,  1681.  Parergon  Secundum,  p.  7C* 
De  Glandulis  Intestinalium,  1681.  Brunner  de  Glandulis  Duodeni.  Francof.  1715. 


556 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


ample  of  Bichat  in  trusting  to  analogy  to  prove  their  existence ; for 
they  are  not  necessary  to  the  secretion  of  raucous  fluid,  as  he  seems 
to  imagine.  Those  in  the  urethra,  first  well  described  by  William 
Cowper,  are  distinct  examples  of  follicles  in  the  genito-urinary  sur- 
face.* The  sinuosities  {lacuna;),  first  accurately  described,  if  not 
discovered  by  Morgagni, j though  not  exactly  the  same  in  confor- 
mation and  structure,  seem  to  be  very  slightly  different. 

The  importance  of  the  muciparous  follicles  in  influencing  both 
the  functions  and  the  morbid  states  of  the  alimentary  mucous  mem- 
brane, renders  it  necessary  to  consider  with  some  detail  the  situa- 
tion, structure,  and  anatomical  peculiarities  of  these  bodies. 

These  do  not  occur  at  all  parts  of  the  alimentary  mucous  mem- 
brane ; but  are  distributed  in  different  modes  in  difierent  regions 
of  the  membrane. 

In  the  oesophagus  they  are  not  numerous,  but  are  observed  like 
small  bodies  about  the  size  of  flattened  pin-heads  in  various  parts 
of  the  membrane,  and  at  irregular  intervals  from  each  other. 
With  a good  glass  may  be  recognized  a minute  aperture  or  pore, 
which  proceeds  from  the  centre  of  the  gland  and  acts  as  a sort  of 
excreting  duct. 

At  the  cardia  these  bodies  become  more  numerous  and  are  more 
closely  set,  so  that  they  form  a sort  of  ring  round  the  cardiac  orifice. 

In  the  stomach  they  are  rather  numerous  along  the  course  of 
the  small  arch.  But  they  are  observed  at  uncertain  intervals  in 
various  other  regions  of  the  stomach.  At  the  pylorus  also  they 
are  abundant,  and  in  that  region  also  they  may  be  more  easily  re- 
cognized than  in  any  other  part  of  the  organ. 

The  duodenum  is  rather  peculiar  as  to  its  glandular  apparatus. 
The  whole  duodenal  mucous  membrane  is  provided  with  numerous 
minute  glandular  bodies,  which  are  more  closely  set  than  in  any 
other  part  of  the  alimentary  canal,  and  give  its  surface  an  appear- 
ance rough  and  irregular,  and  a firmer  consistence  than  elsewhere. 
These  bodies  nevertheless  are  not  so  distinctly  observed  in  man  as 
in  certain  animals,  for  instance  the  horse,  ox,  stag,  dog,  and  wolf. 
These  glandular  or  follicular  bodies  are  believed  to  be  seated  mostly 
in  the  submucous  cellular  tissue. 

The  upper  part  of  jejunum  does  not  present  many  glandular 
bodies,  and  indeed  is  most  commonly  without  them  for  several  feet. 

* * Two  new  Glands  near  the  Prostate  Gland,  with  their  Excretory  Ducts.  By  Mr 
William  Cowper.  Phil.  Transactions,  No.  258,  p.  364. 

+ Adversaria  Anatomica,  IV.  8,  9,  &c. 


MUCOUS  MEMBRANE. 


557 


But  the  lower  part  of  the  small  intestine,  and  what  is  named  ileum^ 
is  provided  with  two  sets  of  follicles,  one  solitary  (^Z.  solitaries)^  or 
consisting  of  single  isolated  follicles,  the  other  aggregated  or  associ- 
ated {glandules  agminates,)  so  as  to  form  a patch,  plexus,  or  cluster. 

The  solitary  glands  begin  to  appear  about  four  or  five  feet  above 
the  lower  end  of  the  ileum.  They  are  not  always  very  distinct  or 
visible.  When  they  are,  they  are  disseminated  like  minute  grains 
through  the  mucous  corion  at  irregular  intervals.  They  are  often, 
nevertheless,  less  conspicuous  at  the  lower  end  of  the  ileum  than  a 
little  higher  up. 

The  aggregated  glands  begin  to  appear  in  the  ileum  about  from 
four  to  six  feet  from  its  lower  end.  From  the  point  where  they 
commence  showing  themselves,  they  are  invariably  disposed  along 
the  antimesenteric  side  of  the  bowel,  or  that  which  is  opposite  to 
the  mesenteric  attachment.  They  appear  in  the  form  of  patches, 
sometimes  affecting  the  circular  shape,  sometimes  irregular,  most 
frequently  elliptical,  with  the  long  diameter  corresponding  to  the 
axis  of  the  bowel.  In  size  they  vary  according  to  the  number  of 
integral  follicles  of  which  each  patch  consists.  High  up  in  the  ileum 
they  are  often  small,  that  is,  not  larger  than  a silver  four-penny 
piece.  But  lower  down  they  becomejarger  and  affect  more  decid- 
edly the  elliptical  figure.  They  are  also  closer  to  each  other  to- 
ward the  lower  portion  of  the  bowel  than  at  its  upper  part. 

These  elliptical  patches  consist  of  a great  number  of  follicles  or 
crypts  placed  contiguous  to  each  other.  The  number  varies  from 
perhaps  20  or  30  to  50,  60,  or  more.  Each  isolated  component 
follicle  is  a small  body  with  a pore  or  orifice  issuing  from  its  centre ; 
and  each  follicle  consists,  so  far  as  can  be  at  present  determined, 
of  a peculiar  sort  of  dense  matter,  which  I think  is  merely  a species 
of  close  filamento-cellular  tissue,  through  which  are  distributed 
many  minute  arteries  and  veins. 

In  colour,  these  patches  are  usually  of  a darker  tint  than  the 
surrounding  mucous  membrane,  mostly  of  a leaden  gray,  or  slate- 
blue  shade ; and  when  viewed  by  transmitted  light,  they  are  like  a 
dark  or  opake  patch  on  the  more  translucent  intestine.  This,  I 
think,  depends  on  the  greater  aggregation  of  their  constituent 
tissue. 

Most  usually  they  are,  in  the  natural  state,  on  a level  with  the 
surface  of  the  adjoining  portion  of  intestine.  They  are  not  very 


558 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


rough  or  irregular ; but  by  the  eye,  or  a good  glass,  it  is  possible 
to  observe  considerable  irregularity  in  surface. 

All  these  characters  become  exaggerated  under  the  influence  of 
disease.  They  then  become  elevated,  rough,  irregular  on  the  sur- 
face, and  their  opacity  is  increased. 

At  the  lower  extremity  of  the  ileum^  where  it  enters  the  ccecum, 
the  whole  membrane  is  often  occupied  with  a large  and  extensive 
patch  of  agminated  glands,  most  extensive  in  the  long  direction  of 
the  bowel,  without  definite  shape,  or  rather  the  whole  of  the  lower 
part  of  the  ileum,  for  the  space  of  from  three  to  four  inches,  consists 
of  a surface  of  agminated  glands. 

The  agminated  glands,  and  also  the  solitary  follicles  of  the  ileum, 
are  generally  larger  and  more  distinct  caeteris  paribus  in  infancy, 
than  in  adult  life.  In  the  bodies  of  infants,  they  are  almost  inva- 
riably easily  seen  and  demonstrated.  In  the  bodies  of  young  sub- 
jects between  14  and  20  or  25,  they  are  still  visible,  sometimes 
very  distinctly.  In  general,  however,  after  this  period,  they  are 
greatly  less  distinct,  and  sometimes  they  cannot  be  recognized  at 
all.  In  old  age  they  cease  to  be  observed. 

In  the  colon,  the  mucous  follicles  are  still  different  both  in  shape 
and  disposition. 

They  appear  in  the  form  of  small  round  oblate-spheroidal  or 
orbicular  bodies,  with  circular  outline  about  one  line  in  diameter, 
not  unlike  millet-seeds,  with  a central  pore  or  aperture.  These 
bodies  are  always  isolated,  and  they  are  placed  at  the  distance  of 
from  half  an  incli  to  one  inch  from  each  other.  They  are  arranged 
all  round  the  mucous  surface  of  the  bowel,  and  are  not,  as  is  ob- 
served as  to  the  aggregated  glands  of  the  ileum,  confined  to  one 
side  of  the  bowel  only.  In  different  subjects  they  are  presented 
with  different  degrees  of  distinctness.  In  some  they  are  scarcely 
visible  ; in  others  they  are  conspicuous.  In  dropsical  subjects  they 
are  usually  very  distinct,  probably  from  their  tissue  being  infiltrated 
with  serum.  Their  structure  appears  to  consist  of  minute  colour- 
less vessels  ramified  in  filamento-cellular  tissue,  and  with  a central 
pore  or  excretory  duct.  They  are  placed  immediately  beneath  or 
in  the  mucous  corion,  which  over  their  surface  is  thin,  and  descends 
through  the  pore  into  the  interior  of  the  gland. 

At  the  lov/er  extremity  of  the-  colon,  or  rather  the  rectum,  there 
are  placed  several  follicles,  often  of  considerable  size.  Their  struc- 
ture is  in  all  respects  similar  to  that  of  those  of  the  colon. 


MUCOUS  MEMBRANE. 


559 


On  the  minute  structure  of  these  follicles,  all  that  is  accurately 
known  is  the  following.  If  we  examine  an  isolated  follicle,  it  pre- 
sents the  most  simple  form  of  glandular  arrangement.  The  intes- 
tinal mucous  membrane  is  continued  through  the  minute  pore, 
which  is  situate  at  the  apex  of  the  follicle  downward  for  about  3; goth 
part  of  one  line,  forming  a blind-sac,  or  cavity  of  a sac,  and  con- 
stituting in  this  manner  a crypt  or  recess.  The  surface  of  this 
short  passage  is  moistened  by  a fluid  which  is  secreted  from  it.  On 
this  surface  are  ramified  an  infinite  number  of  minute  arteries  and 
veins,  which  constitute  the  vascular  system  of  the  follicle.  Be- 
neath the  mucous  membrane  of  the  crypt  is  situate  a close  but  fine 
filamentous  tissue,  which  surrounds  the  arteries  and  veins  now  men- 
tioned. This  filamentous  tissue  is  gradually  connected  with  that 
of  the  contiguous  intestine.  The  existence  of  excretory  ducts  on 
the  cryptic  membrane  has  not  been  demonstrated.  It  is  most  pro- 
bable that  upon  the  free  surface  of  this  the  arteries  open. 

The  close  filamentous  tissue  now  mentioned  as  forming  the  pa- 
renchyma of  the  follicle,  it  is  difficult  to  demonstrate  in  the  healthy 
state.  Some  describe  as  silvery  white,  others  as  slightly  yellow. 
When  the  follicles  are  affected  by  inflammation,  it  becomes  thick, 
hard,  and  swelled,  and  it  is  then  more  distinctly  seen.  It  then  also 
becomes  reddish,  or  yellow,  or  orange-coloured. 

What  the  structure  of  the  isolated  follicle  is,  such  is  that  of  the 
aggregated  follicles,  which,  indeed,  are  merely  many  isolated  fol- 
licles adjoining  to  each  other,  or  united  so  as  to  form  a patch,  {ag- 
men)  {glandules  agminate^.  Each  agminated  gland  has  its  pore,  its 
crypt,  its  cryptic  membrane,  its  blood-vessels,  and  its  cellular  tissue. 

These  glands  have  been  denominated  muciparous,  and  are  sup- 
posed to  secrete  mucus.  The  fluid  which  issues  from  them  appears 
to  be  thinner  and  more  liquid  than  mucus.  It  may,  however,  un- 
dergo changes  after  its  secretion. 

In  certain  regions  of  the  mucous  membranes,  more  especially  at 
tbeir  connections  with  the  skin,  are  found  minute  conical  eminences 
denominated  papilles.  They  are  distinctly  seen  in  the  mucous 
membrane  of  the  tongue,  where  they  vary  in  size  and  shape,  and 
in  the  body  named  clitoris.  They  are  elevations  belonging  to  the 
raucous  corion,  and  they  are  liberally  supplied  by  blood-vessels, 
the  veins  of  which  present  an  erectile  arrangement,  and  with  mi- 
nute nervous  filaments.  Of  the  intimate  structure  of  these  bodies, 
however,  little  more  is  known.  They  are  covered  by  a true  epi- 
dermis. 


560 


GNEERAL  AND  PATHOLOGICAL  ANATOMY. 


In  the  stomach,  duodenum,  and  ileum,  this  membrane  is  collect-  ' 
ed  into  folds  or  plaits,  which  have  received  in  the  former  situation 
the  name  of  rug(R  or  wrinkles,  and  in  the  latter  the  name  of  plicm  j 
or  folds,  and  valvula  conniventes  or  winking  valves.  In  the  vagina  I 
also  are  transverse  rugce^  which  in  like  manner  are  folds  or  dupli- 
catures  of  its  mucous  membrane.  Those  of  the  oesophagus  are  lon- 
gitudinal, and  have  been  described  by  Bleuland.  In  the  tracheo-  | 
bronchial  membrane,  and  in  the  membranous  and  spongy  portions 
of  the  urethra,  we  find  them  in  the  shape  of  minute  plates  or  wrinkles 
in  the  long  direction  of  their  respective  tubes,  but  rarely  of  much 
length.  These  folds  or  plaits  are  quite  peculiar  to  the  mucous 
membranes ; and  the  object  of  them  appears  to  be  to  increase  the  i 
extent  of  surface,  and  to  allow  the  membrane  to  undergo  consider- 
able occasional  distension. 

In  certain  points,  where  a communication  is  observed  between 
the  general  mucous  surface  and  the  cavities  or  recesses  of  particu- 
lar regions,  anatomists  have  not  demonstrated  a mucous  membrane, 
but  have  inferred  its  existence  as  a continuation  of  the  general 
surface.  In  the  tympanal  cavity  to  which  the  Eustachian  tube  leads, 
the  existence  of  a mucous  or  fibro-mucous  membrane  is  rather  pre- 
sumed from  analogy  than  proved  by  actual  observation.  We  know 
that,  where  the  biliary  and  pancreatic  ducts  enter  the  duodenum, 
and  for  a considerable  space  towards  the  liver,  the  interior  appear- 
ance is  that  of  a fine  mucous  surface  provided  with  lacun<z  and  vil- 
losities ; but  it  is  impossible  to  say  at  what  point  of  the  hepatic 
duct,  or  of  the  smaller  canals  of  which  it  is  formed,  the  mucous 
membrane  terminates. 

The  tracheal  membrane,  when  traced  to  the  bronchial  divisions, 
presents  no  arrangement,  either  of  papillcB,  piles,  or  villosities ; and 
nothing  is  perceived  except  a smooth  uniform  surface,  of  a colour 
between  gray,  dun,  and  red  or  purple,  which  is  moistened  with  a 
viscid  semitransparent  fluid,  and  which  is  as  like  the  peritonaeum 
as  the  intestinal  mucous  membrane. 

In  the  ultimate  divisions  of  the  bronchial  tubes,  the  mucous  mem- 
brane follows  the  anatomical  arrangement  of  these  tubes  to  their 
extremities.  It  was  at  one  time  imagined,  that  these  tubes  terminat- 
ed in  enlarged  or  dilated  chambers,  which  were  termed  by  Malpighi 
ampullul(B^  and  by  others  air-cells  and  vesicles ; and  it  was  further 
believed,  especially  by  Willis  and  Senac,  that  various  vesicles  or 
ultimate  chambers  placed  at  the  terminal  ends  of  bronchial  tubes 
communicated  with  each  other  in  the  substance  of  the  lungs.  These 


MUCOUS  MEMBRANE 


561 


cells,  indeed,  Willis  represents  as  clustered  together  like  grapes. 
It  is  certain  that  this  is  not  established  by  observation. 

When  a bronchial  tube  is  traced  to  its  further  extremity,  it  ter- 
minates not  in  an  enlarged  chamber  or  cell,  but  merely  in  a blind 
sac  or  cavity ; and  this  sac  does  not  communicate  with  others. 
The  bronchial  tubes,  in  short,  though  divided  to  great  minuteness 
in  the  substance  of  the  lungs,  preserve  their  character  of  tubes  gra- 
dually tapering  and  diminishing,  but  do  not  form  ampullulae,  or 
vesicles  or  cells  properly  so  named. 

It  is  nevertheless  convenient  to  retain  the  name  of  cells  or  ve- 
sicles, understanding  thereby  merely  the  terminal  ends  of  the 
bronchial  tubes. 

Lastly,  the  situation  where  the  existence  of  the  mucous  system, 
though  believed,  is  most  uncertain,  is  in  the  interior  of  the  vasa 
deferentia,  and  where  they  take  their  origin  from  the  vasa  effe- 
rentia  of  the  testis.  Regarding  the  organization  of  these  tubes 
no  sensible  evidence  can  be  obtained,  and  whatever  is  stated 
concerning  it  is  the  result  of  analogical  inference. 

Though  these  membranes  have  been  designated  by  the  gene- 
ral name  of  mucous.^  it  is  not  to  be  understood  that  the  action 
of  their  surface  is  in  every  situation  the  same.  It  is  not  easy 
to  limit  the  signification  of  the  term  mucus ; for  it  appears  that 
this  fluid  varies  in  the  nasal  passages,  in  the  tracheal  and  bronchial 
membrane,  in  the  oesophagus,  stomach,  and  intestines,  and  in  the 
urinary  bladder  and  m-eters.  But  it  may  be  stated  as  a certain 
fact,  that  many  parts  of  the  two  mucous  surfaces  never  in  the  healthy 
state  secrete  any  modification  of  this  animal  matter ; and  in  others 
the  membrane  is  almost  always  moistened  by  a different  fluid.  The 
mucous  or-villous  membrane  of  the  eyelids  is  never  in  the  healthy 
state  occupied  with  mucus,  but  is  uniformly  moistened  with  the 
tears ; the  membrane  of  the  mouth  and  throat  is  moistened  with 
saliva  only ; the  urethra  presents  a peculiar  viscid  fluid,  which 
seems  to  exude  from  many  minute  vessels  opening  along  its  sur- 
face, as  in  the  lacunce,  but  which  is  widely  different  from  mucus. 
All  those  parts,  in  short,  which  are  not  in  perpetual,  but  only  oc- 
casional, contact  with  foreign  or  secreted  substances,  seem  to  pre- 
sent no  mucus  in  the  healthy  state : whereas  the  surfaces  of  the 
stomach,  intestines>  gall-bladder,  and  urinary  bladder,  are  con- 
stantly covered  with  a quantity,  more  or  less  considerable,  of  this 
animal  secretion. 


N n 


562 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


The  chemical  properties  of  mucous  membranes  are  completely 
unknown.  The  analysis  of  the  fluid  secreted  by  them  has  been 
executed  by  Fourcroy,  Berzelius,  and  others,  but  is  foreign  to  the 
subject  of  this  work. 

The  mucous  membranes  are  most  liberally  supplied  with  blood 
by  vessels  which  are  both  large  and  numerous.  This  is  proved  not 
only  by  the  phenomena  of  injections,  but  by  the  red  colour  of  which 
many  of  their  divisions  are  the  seat.  Tl.is  coloration,  as  well  as 
the  injectibility,  is  not  indeed  uniform  ; for  in  certain  regions  mu- 
cous surfaces  are  pale  or  light  blue  : in  others  their  redness  is  con- 
siderable. 

Thus,  in  those  regions  in  which  the  mucous  membranes  coalesce 
with  the  periosteum,  forming  fibro-mucous  membranes,  e.  g.  in  the 
facial  sinuses,  the  tympanal  cavity  and  the  mastoid  cells,  the  colour 
is  pale-blue,  or  approaching  to  light-lilac.  In  the  bladder,  in  the 
large  intestines,  in  the  excretory  ducts,  in  general,  though  pale, 
this  colouring  becomes  more  vivid.  In  the  pulmonic  mucous  mem- 
brane it  is  a slate-blue,  verging  to  pale  pink.  In  the  stomach,  duo- 
denum, small  intestines,  and  the  vagina,  it  becomes  still  more 
marked.  In  the  uterus  it  varies  according  to  the  period  or  the  in- 
tervals of  menstruation. 

If  these  vessels  be  examined  in  the  gastro- enteric  mucous  mem- 
brane, in  which  they  are  probably  most  numerous,  they  are  found 
to  consist  of  an  extensive  net-work  of  capillaries  divided  to  an  in- 
finite degree  of  minuteness,  mutually  intersecting  and  spreading 
over  the  upper  or  outer  surface  of  the  mucous  corion.  This  vas- 
cular net-work,  though  demonstrated  by  Ruysch,  Albinus,  tialler, 
and  Bichat,  has  been  very  beautifully  represented  in  the  delinea- 
tions of  Bleuland,  who  thinks  he  has  traced  their  minute  ramifica- 
tions into  the  as  above  stated.  These  minute  vessels  are  de- 
rived from  larger  ones,  which  creep  through  the  submucous  cel- 
lular tissue,  and  which  are  observed  to  penetrate  the  mucous  corion 
to  be  finally  distributed  at  its  exterior  surface.  The  substance  of 
this  membrane  itself  appears  to  receive  few  or  no  vessels.  It  is 
well  known,  that  the  vessels  which  supply  the  mucous  surfaces,  enter 
between  the  folds  of  the  serous  membranes,  at  which  they  are  in  the 
form  of  considerable  trunks.  Having  penetrated  between  the  folds 
of  these  membranes,  they  divide  in  the  subserous  cellular  tissue 
into  branches,  the  size  of  which  is  considerable  ; and  here  they  form 
those  numerous  anastomotic  communications  which  constitute  the 

4 


MUCOUS  MEMBRAKE. 


563 


arches  so  distinctly  seen  in  the  ileum.  From  the  convexity  of  these 
arches  in  general,  are  sent  off  the  small  vessels,  which  are  then  fitted, 
after  passing  through  the  muscular  layer  and  the  submucous  tissue, 
to  enter  the  mucous  corion. 

The  capillary  terminations,  then,  of  these  arteries,  and  their  cor- 
responding veins,  constitute  the  physical  cause  of  the  coloration  of 
the  mucous  membranes.  This  coloration,  however,  is  not  at  all 
times  of  the  same  intensity  in  the  same  membrane,  and  varies 
chiefly  according  to  the  state  of  the  organ  which  the  membrane 
covers.  The  coloration  of  the  gastro-enteric  mucous  membrane 
undergoes,  even  within  the  limits  of  health,  many  variations.  Thus, 
according  to  the  absence  or  presence  of  such  foreign  substances  as 
are  taken  at  meals,  the  mucous  membrane  is  pale,  or  presents 
various  shades  of  redness.  At  the  period  of  menstruation  the  ute- 
rine mucous  membrane  becomes  red  and  injected.  Pressure  on 
any  of  the  venous  vessels  renders  the  mucous  membrane  blue, 
purple,  or  livid,  as  is  seen  in  prolapsus,  and  more  distinctly  in 
asphyxia,  in  which  all  the  mucous  membranes  assume  a livid  tint. 
(Bichat.)  The  varieties  of  red  colour  observed  in  the  gastric  mu- 
cous membrane  by  Dr  Yellowly  are  to  be  ascribed  partly  to  the 
latter  cause,  partly  to  the  vascular  redness  which  the  presence  of 
foreign  bodies  occasions.* 

Where  death  is  the  result  of  asphyxia,  rapid  or  slow,  the  gastric 
and  intestinal  mucous  membranes  are  often  much  loaded  with 
blood.  In  death  from  disease  of  the  heart,  when  the  fatal  event  is 
preceded  by  great  anguish,  I have  often  seen  the  gastric  mucous 
membrane  of  a deep  red  colour,  and  occasionally  livid  and  approach- 
ing to  black.  The  dependant  portions  of  the  intestinal  convolu- 
tions are,  under  the  same  circumstances,  much  loaded  with  blood, 
mostly  in  veins.  These  appearances  must  not  be  confounded  with 
inflammation.  They  merely  imitate  that  process,  and  are  pseudo- 
inflammatory. 

The  pulmonary  division  of  this  membrane  is  of  an  ash-gray  or 
dun  colour,  inclining  to  pale-blue  or  light-red.  These  colours 
vary,  nevertheless,  according  to  the  facility  or  the  difficulty  with 
which  the  blood  moves  through  the  pulmonary  capillary  system. 
It  is  also  freely  supplied  with  blood-vessels  derived  chiefly  from  the 
bronchial  arteries.  These  vessels,  after  accompanying  the  bron- 

* Observations  on  the  vascular  appearance  in  the  Human  Stomach,  which  is  fre- 
quently mistaken  for  inflammation  of  that  organ.  By  John  Yellowly,  M.  D.  &c, 
Medico-Chirurg.  Trans.  Vol.  IV.  p.  371. 


564 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


chial  tubes  and  their  successive  subdivisions,  divide  into  minute  j 
branches  which  penetrate  the  mucous  corion,  which  here  is  white, 
dense,  and  fibrous,  and  after  anastomosing  with  the  capillaries  of  | 
the  pulmonary  artery  and  veins,  form  a minute  delicate  net-work 
on  the  outer  surface  of  the  pulmonary  mucous  membrane.  Ac- 
cording to  Reisseissen,  to  whom  we  are  indebted  for  a careful  exa- 
mination of  these  vessels,  a successful  injection  of  them  from  the  ! 
bronchial  arteries,  renders  the  whole  mucous  membrane  of  the  bron- 
chi entirely  red  to  the  unassisted  eye.* 

The  termination  of  arteries  at  the  mucous  surfaces  has  at  all  times 
occupied  the  attention  of  anatomists  and  physiologists ; but  it  is  ij 
unfortunately  not  a matter  of  sensible  demonstration.  The  thin 
serous  or  sero-mucous  fluid  with  which  they  are  at  all  times  mois- 
tened, has  led  every  author  almost,  and  among  the  rest  Haller  and 
Bichat,  to  infer  the  existence  of  arteries  with  open  mouths,  or  what  i 
are  termed  exhalant  vessels.  If  this  be  entirely  denied,  the  patho- 
logist, as  well  as  the  physiological  enquirer,  is  deprived  of  a con- 
venient source  of  explaining  many  vital  phenomena.  It  has  been 
admitted,  nevertheless,  more  on  analogical  than  direct  proofs.  The 
injections  of  Bleuland  are  the  only  experiments  after  those  of  Kawe 
Boerhaave,  which,  so  far  as  I am  acquainted,  tend  to  confirm  the 
conclusion.f  These  experiments,  nevertheless,  require  to  be  re- 
peated and  extended. 

That  lymphatics  are  distributed  to  mucous  membranes  is  a point 
well  established.  Cruikshank  saw  the  lymphatics  proceeding  from 
the  pulmonic  mucous  membrane  loaded  with  blood  in  persons  and 
animals  dying  of  haemoptoe.  Their  existence  in  the  gastro-enteri- 
tic  mucous  membrane  has  been  long  established. 

The  mucous  surfaces  are  also  freely  supplied  by  nervous  twigs 
and  filaments,  derived  in  general  from  the  nerves  of  automatic  life. 

It  is  a mistaken  view,  nevertheless,  to  ascribe  to  these  filaments 
the  sensibility  and  other  properties  of  the  mucous  surfaces.  These  | 
mucous  membranes  possess  intrinsically  certain  vital  properties  in-  | 

dependently  of  the  nervous  filaments  with  which  they  are  supplied  ; I 

and  the  principal  use  of  these  filaments  appears  to  be  to  regulate 
these  properties,  especially  that  of  secretion. 

* Franz  Daniel  Reisseissen,  ueber  die  Ban  der  Lungen,  u.  s.  w.  Berlin,  1822. 

-f-  Experimentum  Anatomicum,  quo  Arteriolamm  Lymphaticarum  existentia  pro- 
babiliter  adstruitur,  &c.  a Jano  Bleuland,  M,  D.  Lug.  Bat.  1784.  Item  ; Jani  Bleu- 
land, M.  D.,  &c.,  Vasculomm  Intestinorum  tenuium  Tunicis  subtilioris  Anatomes 
Opera  Detegendorum  Descriptio  Iconibus  illustrata.  Trajecti,  1797. 


MUCOUS  MEJIBRANE. 


565 


The  progressive  development  of  mucous  membrane,  and  espe- 
ciall)^  of  its  has  been  studied  by  Meckel  in  the  intestinal  tube. 
This  anatomist  states,  that  in  the  beginning  of  the  third  month  he 
first  recognized  them  distinctly  in  the  form  of  long  plaits,  (Langen- 
falten)  thickly  set  on  the  inner  surface  of  the  intestine,  and  scarce- 
ly indented  on  their  free  edge.  The  number  and  depth  of  these 
folds,  and  their  indentations,  are  gradually  increased,  till  in  the  end 
of  the  fourth  month,  sometimes  sooner,  in  place  of  the  simple  long 
plaits,  the  observer  may  distinguish  an  irregular  multitude  of  mi- 
nute elevations,  which  become  proportionally  larger  at  a later  pe- 
riod of  foetal  existence.  He  therefore  infers  that  the  villi  are  form- 
ed by  the  gradual  indentation  and  decomposition  (Zerfallung)  of 
simple  longitudinal  plaits.* 

The  connection  between  the  mucous  membranes  and  the  skin,  I 
have  elsewhere  stated,  was  first  well  demonstrated  by  Bonn,  who 
traces  their  mutual  approximation  and  reciprocal  transition  into 
each  other,  and  represents  the  former  as  an  interior  production  of 
the  latter  enveloping  the  internal  as  the  skin  incloses  the  external 
organs.!  This  view  has  been  adopted  by  Meckel  and  Bedard,  to 
whom  I refer  for  the  proofs  of  its  accuracy.  I cannot  conclude 
the  subject,  however,  without  observing  that  one  of  the  most  con- 
clusive arguments  in  its  favour  is  derived  from  the  circumstances 
of  the  development  of  the  intestinal  canal  during  the  first  months 
of  uterine  life.  The  history  of  this  curious  process,  which  has  been 
so  happily  investigated  by  Wolff  and  OkenJ,  and  so  well  traced  by 
Meckel,  shows  that  at  this  period  the  gastro-enteric  mucous  mem- 
brane, which  is  previously  formed  by  the  vitellar  membrane  of  the 
ovum,  and  the  allantois  or  vesical  membrane,  which  afterwards 
forms  the  genito-urinary  mucous  surface,  are  in  direct  communica- 
tion on  the  median  line,  and  afterwards  at  the  navel  with  the  skin 
or  exterior  integument. § The  detailed  history  of  this  process  be- 
longs, however,  rather  to  special  than  to  general  anatomy  ; and  I 
notice  it  here  as  the  strongest  proof  which  occurs  to  me  of  the  con- 
nection between  the  skin  and  the  mucous  membranes,  and  as  an 


’ Deutches  Archiv  fur  die  Physiologie  von  J.  F.  Meckel,  3ter  Band.  Halle  und 
Berlin,  1817.  P.  68. 

-f-  Specimen  Anatomico-Medicum  Inaiig.  &c.  Continuationibus  Membranarum,  &c. 
&c.  In  Sandifort  Thes.  Vol.  II.  p.  265.  Rotterod.  1769. 

Jenaiscbe  Zeitung,  S.  207-208. 

§ Deutches  Archiv  fiir  die  Physiologie,  Dritter  B.  Halle  und  Berlin,  1817. 


566 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


anatomical  fact  which  furnishes  the  solution  of  some  curious  con- 
genital malformations,  and  of  various  morbid  processes,  which  af- 
fect simultaneously,  successively,  or  occasionally,  both  orders  of 
membranes. 


Section  II. 


The  morbid  states  of  the  mucous  membranes  are  numerous  and 
important,  and  constitute  a large  proportion  of  the  diseases  which 
daily  come  under  the  notice  of  the  physician.  Generally  speaking, 
these  morbid  states  may  be  referred  to  the  following  heads,  inflam- 
mation and  its  effects,  sero-albuminous  effusion,  suppuration  and 
idceration,  hemorrhage,  induration  and  thickening  producing  con- 
traction or  stricture,  new  growths,  and  malformation. 


T.  The  inflammatory  process  in  this  tissue  gives  rise  to  a con- 
siderable number  of  diseases  which  long  usage  has  distinguished 
according  to  the  region,  the  mucous  membrane  of  which  is  diseased. 
These  affections,  which  agree  in  general  characters,  and  vary  only 
in  certain  points  depending  on  situation  and  local  peculiarity,  may 
be  conveniently  arranged  according  as  they  take  place;  A.  in  the 
cephalic  or  facial  mucous  membrane;  B.  in  the  tracheo-bronchial 
mucous  membrane ; C.  in  the  gastro-enteric  membrane ; and  D. 
in  the  genito-urinary  mucous  membrane. 


Cephalic 
■ division. 


Tracheo- 

B.  bronchial 
division. 

Alimen- 

C. tary  divi- 

sion. 

Genito- 

D.  Urinary 
division. 


i Eyelids  and  eye, 

) Nasal  duct, 

I Nasal  passages, 

( Tympanal  cavity, 
i Throat, 

) Larynx, 

1 Trachea, 

( Bronchial  membrane, 

iffisophagus. 

Stomach, 

Ileum, 

Colon, 

! Ureter, 

Bladder, 

Urethra. 

Womb  and  vagina. 


Ophthalmia. 

Epiphora. 

Coryza. 

Tympania. 

Laryngia. 

Tracheitis. 

Bronchia. 

ffisophagia. 

Gasteria. 

Enteria. 

Colonia. 

Ureteria. 

Cystidia. 

Urethria. 

Metria. 


Oza;na. 

Otorrhoca. 

Cynanche  laryngaea. 

Croup  ; catarrh. 

Bronchitis  ; catarrh. 
Inflammation  of  ossophagus. 
Dyspeptic  symptoms. 
Diarrhoea. 

Dysenteria. 

Catarrhus  vesica. 
Gonorrhoea,  Blennorrhagia. 
Leucorrhcca,  &c. 


In  these  several  divisions  of  the  mucous  surfaces  the  anatomical 
characters  of  inflammation  are  much  the  same.  The  process  takes 
place  under  two  varieties,  the  spreading  or  diffuse,  which  extends 
over  the  surface  of  the  membrane  ; and  the  punctuate  or  circum- 
scribed, which  affects  many  points  at  the  same  time.  The  mem- 
brane becomes  red,  injected,  traversed  by  minute  red  points  and 


4 


CEPHALIC  MUCOUS  MEMBRANES. 


567 


vessels,  soraetiines  arborescent  or  asteroid,  sometimes  punctular  or 
in  minute  points,  occasionally  in  linear  streaks,  and  not  unfrequent- 
ly  in  red  patches ; the  surface  becomes  swelled  and  villous  or  pulpy ; 
and  the  proper  secretions  of  the  part  are  altered  into  sero-albumi- 
nous  fluid,  puriform  mucus,  or  actual  purulent  matter.  In  situa- 
tions in  which  there  is  epidermis,  as  in  the  mouth  and  gullet,  this 
is  elevated  into  minute  vesicles  and  blisters  forming  aphtha ; or 
the  membrane  is  cast  off  in  the  form  of  exfoliated  patches.  In  the 
gastro-enteric  membrane  the  villi  are  removed,  and  the  surface  is 
rendered  plane  like  that  of  the  rectum  or  bladder.  The  inflamma- 
tion may  terminate  in  the  formation  of  ulcers  ; or  in  induration  and 
permanent  thickening  of  the  mucous  tissue  by  effusion  of  lymph 
beneath  it,  and  into  its  substance.  The  follicles  are  at  the  same  time 
liable  to  become  enlarged  and  vascular,  and  occasionally  proceed 
to  ulceration  ; but  this  is  more  fi'eqnent  in  the  chronic  form  of  the 
process.  The  minute  peculiarities  will  be  more  conveniently  noticed 
under  their  respective  heads. 

A.  CEPHALIC  MUCOUS  MEMBRANES. 

§ 1.  Ophthalmia  serosa  et  puriformis. — The  ophthalmic  mucous 
membrane  (^conjunctiva)  may  be  become  the  seat  of  inflammation, 
with  secretion  of  sero-albuminous  fluid,  puriform  fluid,  or  purulent 
matter.  In  the  former  case,  in  which  the  natural  fluid  appears 
simply  to  be  much  augmented,  the  inflammation  is  confined  chiefly 
to  the  ocular  conjunctiva,  which  is  reddened  and  elevated,  forming 
in  severe  cases  round  the  cornea  a prominent  ring  or  excrescence, 
which  appears  to  start  from  the  eyelids — a state  denominated  by 
the  ancient  surgeons  chasm  or  gaping  (chemosis),  because  a small 
opening  corresponding  to  the  cornea  is  left  in  the  centre  of  the 
swelled  membrane.  This  severe  form  of  the  disease  occasionally 
terminates  in  suppuration,  ulceration,  or  sloughing. 

Of  the  second  form,  two  varieties  are  mentioned,  the  purulent 
opbthalmy  of  infants,  and  the  purulent  ophthalmy  which  afi'ects 
epidemically  large  bodies  of  men  in  close  intercourse  with  each 
other.  In  both  cases,  the  mucous  surface  of  the  eye  and  eyelids  is 
very  red,  swollen,  villous,  and  pulpy,  and  puckered  into  folds  by 
the  violent  action  of  the  muscles ; while  the  cornea  is  generally 
completely  concealed  by  more  or  less  chemosis,  and  the  eyelids  are 
everted.  After  continuing  in  this  state  for  eight  or  ten  days  dis- 
charging much  puriform  yellow  fluid,  it  may  terminate  in  infants 


568 


GENERAL  AND  PATHOLOGICAL  ANATOMY, 


in  resolution,  but  more  generally  produces  specks  or  opacity  of  the 
cornea,  ulceration,  pustules,  or  chronic  inflammation  and  thicken- 
ing of  the  cornea,  rendering  that  tunic  opaque.  In  adults,  pro- 
ceeding much  in  the  same  manner,  its  effects  are  generally  more 
serious.  If  it  do  not  at  an  earlier  period  of  the  disease  cause  opa- 
city, the  cornea  may  he  ruptured  partially  or  generally,  so  as  to 
allow  the  eseajie  of  the  humours.  The  membranous  inflammation 
becoming  in  all  cases  also  chronic,  the  surface  of  the  conjunctiva 
becomes  irregular  by  numerous  minute  hardish  eminences  or  gra- 
nulations; and  this  granularstate  of  thepalpebral  conjunctiva, 
originally  an  efihct,  becomes  afterwards  a cause  of  further  inflamma- 
tion. 

The  puriform  ophthalmy  originating  from  the  gonorrhoeal  poison, 
though  differing  in  its  cause,  is  the  same  in  its  pathological  effects. 

Q.  A pustular  form  of  ophthalmy  is  sometimes  observed.  It 
consists  in  the  appearance  of  minute  eminences  of  the  sclerotic  mu- 
cous membrane  near  the  circumference  of  the  cornea.  These  bo- 
dies, which  may  be  considered  either  as  aphthae  or  pustules,  are 
conoidal,  and  surrounded  by  a cluster  of  vessels  which  run  into 
them  either  all  round  in  a circular  area,  or  from  one  side,  most 
commonly  the  temporal.  When  they  are  situate  a line  or  two  from 
the  margin  of  the  cornea,  they  are  broad  and  flattened.  This  dis- 
ease seldom  under  proper  treatment  advances  to  suppui’ation  or  ul- 
ceration ; and  I have  seen  it  disappear  in  thirty  hours  after  being 
first  seen.  It  seems  in  some  instances  to  consist  in  a punctuate 
deposition  of  lymph,  in  others  to  be  a peculiar  concentration  of 
blood-vessels.  It  is  not  impossible  for  it,  however,  to  proceed  to 
suppuration  and  form  a minute  abscess  of  tbe  conjunctiva.  When 
these  pustular  eminences  appear  in  the  corneal  mucous  membrane, 
they  generally  pass  into  ulcers. 

In  some  instances,  with  abatement  of  pain,  diminution  of  swell- 
ing, and  alleviation  of  other  symptoms,  the  vessels  appear  much 
distended  and  distinct,  though  tortuous,  the  membrane  is  thickened 
in  patches  or  continuously,  and  sero-albuminous  fluid  is  deposited 
in  spots  or  along  the  course  of  the  vessels.  These  appearances 
mark  the  transition  of  the  disease  into  the  chronic  form.  Their 
persistence  too  often  leaves  the  superficial  speck  (nebula),  the  tri- 
angular web,  (j)terygium),  or  the  opaque  spot,  (leucoma.) 

§ 2.  Watery  eye ; Epiphora. — The  mucous  membrane  of  the  eye 
and  eyelids  communicates  with  that  of  the  nostrils  by  the  narrow 
tube  termed  lacrymal  duct.  A minute  capillary  opening  at  the 

3 


CEPHALIC  MUCOUS  MEMBEANES. 


569 


nasal  extremity  of  each  eyelid,  termed  lacrymal  {piinctum  lacry- 
mnle),  forms  the  upper  or  palpebral  end  of  this  canal ; and  its  in- 
ferior or  nasal  extremity  is  a considerable  opening  in  the  lower 
nasal  passage,  between  the  lower  spongy  bone.  This  canal  is  lined 
by  a fibro-mucous  membrane,  the  free  surface  of  which  is  moisten- 
ed by  a tliin  semitransparent,  glairy  fluid,  not  like  the  mucus  of  the 
nasal  or  tracheal  membrane,  but  merely  viscid  enough  to  facihtate 
the  descent  of  the  tears,  and  to  maintain  a free  communication  be- 
tween the  eyelids  and  nostrils.  This  membrane  may  be  inflamed 
in  any  part  of  its  course,  especially  at  the  palpebral  extremity ; and 
the  swelling  attendant  on  this  process  in  a canal  so  narrow  produces 
a temporary  obstruction  to  the  transmission  of  the  tears, — consti- 
tuting the  simple  and  acute  form  of  the  watery  eye  or  epiphora. 
In  ordinary  circumstances  this  terminates  in  resolution,  and  the 
canal  again  becomes  pervious  in  a few  days.  In  more  severe  cases, 
however,  either  in  consequence  of  thickening  of  the  fibro-mucous 
membrane,  or  the  effusion  of  albuminous  fluid,  the  obstruction  is 
more  permanent ; and  if  not  seasonably  removed,  may  induce  se- 
condary inflammation  of  the  parietes  of  the  canal,  and  ulceration 
and  false  openings ; (fistula.)  In  all  cases  the  inflammatory  pro- 
cess may  affect  the  subjacent  periosteum  of  the  lacrymal,  nasal,  and 
superior  maxillary  bones,  and  induce  caries  in  one  or  more  of  them. 
With  or  without  this  latter  complication,  the  disease  constitutes  la- 
crymal fistula.  In  either  mode  it  is  sometimes  the  result  of  syphi- 
lis, and  very  often  where  mercury  has  been  given  for  the  treatment 
of  that  disease- 

similar  disease  of  the  lacrymal  duct  may  take  place  in  conse-  * 
quence  of  previous  chronic  inflammation  of  the  eyelids  and  Meibo- 
mian glands. 

The  mucous  membrane  of  the  nasal  passages  is  inflamed  in  Co- 
ryza.^— an  affection  forming  the  preliminary  part  of  catarrh.  A 
secondary  coryza  occurs  in  nasal  polypus ; and  ozana,  which  con- 
sists in  chronic  suppurative  inflammation  of  the  nasal  membrane 
lining  the  nasal  and  covering  the  spongy  bones,  is  always  preceded 
by  similar  inflammation.  The  same  process  is  not  unfrequent  in 
the  fibro-mucous  membrane  of  the  maxillary  sinus,  in  which  it  ge- 
nerally proceeds  to  suppuration,  forming  abscess  of  that  cavity. 

§ 3.  Otitis. — The  membrane  of  the  external  auditory  passage  is, 
strictly  speaking,  neither  skin  nor  mucous  membrane,  but  a tex- 
ture intermediate  between  both.  In  its  morbid  relations  it  is,  how- 


570 


GENERAL  AND  PATHOLOGICAL  ANATOMY". 


ever,  more  closely  connected  with  the  latter,  and  is  often  the  seat 
of  inflammation  producing  a yellow  puriform  discharge  {otorrhoea), 
from  the  outer  surface  of  the  tympanal  membrane,  and  the  mem- 
brane lining  the  ear-hole.  The  membrane  is  then  red,  soft,  villous, 
and  highly  tender.  The  average  duration  of  this  disease  is  from 
fifteen  days  to  three  weeks,  after  which  the  fluid  discharged  becomes 
thicker,  and  in  colour,  consistence,  and  odour,  resembles  caseous 
matter.  The  ceruminous  glands  are  disordered  during  its  pre- 
sence ; but  as  it  recedes  their  secretion  becomes  abundant. 

§ 4.  Tympania. — Though  the  membrane  of  the  tympanal  cavity 
and  the  Eustachian  tube  presents  a smooth  uniform  surface,  moist- 
ened by  a thin  watery  fluid  possessing  little  resemblance  to  mucus, 
yet,  as  continuous  with  the  naso-guttural  membrane,  and  as  similar 
to  that  of  the  facial  sinuses,  it  may  be  placed  in  pathological  pro- 
perties in  this  situation.  Bichat  indeed  corrects  the  error  of  those 
anatomists  who  represent  the  membrane  of  the  tympanal  cavity  as 
periosteum ; but  in  his  anxiety  to  maintain  its  mucous  he  overlooks 
its  fibrous  character.  Its  adherent  surface  cannot  be  distinguished 
from  the  periosteum  of  the  bones  to  which  it  adheres.  When  re- 
moved and  dried  it  is  thin,  crisp,  and  semitransparent.  During 
the  inflammatory  process  it  becomes  red,  thick,  soft,  and  actually 
villous ; and  it  secretes  first  serous,  afterwards  yellow  puriform 
fluid,  which  cannot  be  distinguished  from  genuine  purulent  matter, 
though  without  ulceration.*  In  this  disease  an  opening  takes  place 
in  the  membrane,  which  becomes  fungous,  or  is  eventually  destroyed; 
the  tympanal  bones  are  discharged  ; and  not  unfrequently  the  in- 
flammatory process  spreading  into  the  mastoid  cells,  fills  these  ca- 
vities with  matter  more  or  less  viscid.  In  sucli  circumstances  it 
may  aflFect  the  periosteal  surface  and  cause  caries  of  the  bones, 
which  are  then  found  denuded  and  rough.  Not  unfrequently  it 
causes  inflammation  of  the  dura  mater^  and  cerebral  membranes, 
and  the  brain  itself. 

§ 5.  Thrush ; Aphthce. — The  mucous  membrane  of  the  mouth 
and  throat  is  liable  to  this  foian  of  inflammation,  which  depends  on 
the  presence  of  epidermis  in  this  region.  It  is  then  elevated  into 
whitish  or  ash-coloured  vesicles  or  blisters,  sometimes  round  or 
oval,  sometimes  irregular.  The  contained  fluid  is  separated  into 
two  parts,  one  albuminous,  forming  the  rudiment  of  new  epidermis, 

* “ Le  cadarre  d’un  homme  expose  a ces  ecoulemens  pendant  sa  vie,  m’a  presente 
une  epaissem-  et  line  rongeur  remarquables  de  la  membrane  du  tympan,  mais  sans 
nulle  trace  d’erosion.”  Anat.  Generale,  Tome  III.  p.  430. 


TRACHEO-BRONCHIAL  MUCOUS  MEMBRANE. 


571 


the  other  serous,  which  escapes  while  the  old  epidermis  is  cast  in 
the  form  of  scab  or  slough. 

The  mucous  membrane  of  the  throat  and  soft  palate  is  affected 
by  diffuse  redness,  swelling,  and  other  marks  of  inflammation 
during  the  sore  throat  of  scarlet  fever.  That  of  quinsy  is  more 
frequently  seated  in  the  submucous  cellular  tissue. 

B.  TRACHEO-BRONCHIAL  MUCOUS  MEMBRANE. 

h.  Inflammation  of  the  tracheo-bronchial  membrane  may  be  dis- 
tinguished as  the  process  is  developed;  Is^,  in  the  larynx;  2c/,  in 
the  windpipe  or  proper  tracheal  membrane  ; 3c/,  in  the  bronchial 
membrane;  and,  4//c,  in  the  small  bronchial  tubes  or  pulmonic 
membrane.  Though  these  inflammations  possess  certain  common 
characters,  each  is  attended  by  peculiarities  which  require  attention. 

§ 1.  a.  Laryngia,  Laryngitis.  CynancUe  Laryngaea,  Laryngia 
acuta. — Though  this  disease  appears  not  to  have  been  unknown  to 
Cullen  and  some  previous  authors,  we  are  indebted  to  Dr  Baillie, 
Dr  Farre,  Dr  Percival,  Mr  Lawrence,  and  Mr  Howship,  for  a 
more  accurate  account  of  its  pathology  than  we  previously  pos- 
sessed. 

The  proper  seat  of  laryngitis,  indeed,  its  characteristic  symptoms 
and  nature,  had  been  overlooked  in  the  attention  paid  to  croup ; 
and  when  it  v/as  first  observed  carefully,  as  in  the  case  of  General 
Washington,  it  was  called  Croup  in  the  adult.  It  is  impossible  to 
deny  that  the  disease  named  laryngitis  affects  children  as  well 
as  adults;  and  it  may  have  often  been  mistaken  for  croup.  From 
this,  however,  laryngitis  differs  in  the  parts  which  it  affects,  in  the 
effects  which  it  produces,  and,  in  short,  according  to  my  own  ob- 
servation, in  its  anatomico-pathological  nature  and  characters ; and 
for  these  reasons  I consider  the  disease  separately. 

It  may  be  stated  as  a well-established  fact,  that  the  symptoms  of 
this  disease  arise  from  inflammation  circumscribed  to  a definite  re- 
gion of  the  larynx.  Though  the  whole  laryngeal  membrane,  from 
the  epiglottis  to  the  tracheal  rings,  is  red  and  swelled,  the  particular 
point  at  which  this  morbid  action  is  most  injurious  is  that  part  of 
the  mucous  membrane  which  covers  the  arytenoid  cartilages,  and 
forms  the  chink  called  glottis.  Though  this  part  of  the  laryngeal 
membrane  may  not  be  more  swelled  than  any  other,  a moderate 
degree  of  swelling  soon  diminishes  the  aperture  so  much  that  inspi- 
ration is  rendered  difficult  or  impossible,  and  the  danger  of  suffo- 


572 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


cation  becomes  urgent.  It  must  nevertheless  be  observed,  that  in 
many  instances  the  margins  of  the  glottis  are  occupied  by  an  cede- 
matous  or  puffy  swelling,  similar  to  that  which  occasionally  affects 
the  eyelids,  prepuce,  and  female  laUa^ — from  sero-albuminous  in- 
filtration of  the  submucous  filamentous  tissue,  and  the  effect  of  which 
is  to  diminish,  or  in  some  instances  to  obliterate,  the  aperture  which 
regulates  the  admission  of  air  into  the  trachea.  The  redness  and 
swelling  of  the  laryngeal  membrane  is  occasionally  more  conspicu- 
ous at  its  posterior  part  than  elsewhere ; and  the  epiglottis  is  some- 
times swelled  and  thickened  with  injection  of  its  membrane ; but 
whatever  variations  the  disease  presents,  its  effect  on  the  membrane 
of  the  glottis  is  uniform;  and  this  aperture  is  either  much  contracted 
or  completely  obliterated. 

With  redness  and  swelling,  the  laryngeal  membrane  is  generally 
occupied  by  thick  viscid  mucus,  which  contributes  by  adhering  to 
the  margins  of  the  glottis  to  obstruct  the  aperture.  It  is  most 
abundant  in  the  recesses  called  sacculi,  where  it  assumes  the  appear- 
ance of  purulent  fluid.  In  some  rare  instances  suppuration  takes 
place  with  breach  of  surface ; and  purulent  abscesses  have  been 
found  between  the  thyroid  or  arytenoid  cartilages,  and  their  in- 
vesting membrane.  Reddening  of  the  tracheal  membrane  is  a 
complication.  Inflammation  confined  chiefly  to  the  membrane  of 
the  epiglottis  is  described  by  Sir  E.  Home  ;*  and  this  with  the 
arytenoid  affection,  Dr  M.  Hall  shows,  is  the  effect  of  the  accidental 
attempt  to  swallow  boiling  water.f 

Of  laryngeal  inflammation  three  terminations  may  be  enume- 
rated; \st,  resolution,  which  takes  place  some  time  between  the  36th 
and  60th  hour ; 2f/,  fatal  suffocation,  which  may  take  place  any 
time  after  the  30th  hour;  and,  M,  a chronic  state,  with  redness  and 
thickening  of  the  mucous  membrane,  sometimes  with  suppuration 
or  ulceration  of  some  part  of  the  organ,  which  may  be  apprehended, 
if  the  disease  continues  without  proving  fatal  for  four  revolutions  of 
24  hours. 

/3.  Laryngia  chronica. — The  latter  result  is  most  usual  after 
attacks  so  lenient  as  not  to  suffocate,  but  too  severe  to  be  completely 
resolved.  The  membrane  then  continues  injected,  thickened,  and 
corrugated,  rendering  the  individual  hoarse  and  incapable  of  laryn- 
geal speech.  The  duplicatures  called  superior  vocal  chords  in  par- 
ticular, are  irregularly  thickened,  partly  by  accumulation  of  blood 
within  their  vessels,  partly  by  effusion  of  sero-albuminous  fluid 
* Transactions  of  a Society,  Vol.  III.  T Medico- Chirurg.  Trans.  Vol.  XI. 


TRACHEO-BRONCHIAL  MUCOUS  MEMBRA.NE. 


573 


into  the  submucous  cellular  tissue.  Often  the  epiglottis  becomes 
much  thickened.  Its  investing  membrane  is  always  reddened  and 
rough.  After  some  time  ulceration  may  take  place  in  the  epiglottis, 
and  destroy  the  top  or  anterior  extremity  of  it.  This  I have  ob- 
served several  times : the  round  apex  of  the  epiglottis  being  cut  off 
as  it  were  transversely  by  ulceration.  In  other  instances,  it  is  merely 
rendered  thick,  rigid,  and  inflexible,  so  that  it  no  longer,  when  the 
tongue  is  depressed,  covers  accui'ately  the  upper  aperture  of  the 
larynx. 

Other  appearances  are  the  following.  The  lower  or  true  vocal 
chords  become  thickened.  The  membrane  forming  the  ventri- 
cles of  the  larynx  (^sacculi  laryngis,)  is  thickened,  and  occasion- 
ally presents  minute  ulcers  of  the  surface.  The  apices  of  the 
arytenoid  membranes  are  red,  thickened,  and  abraded  or  ulcerated; 
and  sometimes  this  ulceration  descends  to  the  subjacent  cartilages 
or  their  perichondrial  covering.  Constantly  the  perichondrium, 
when  the  disease  lasts  any  time  or  has  recurred  several  times,  is 
thickened  and  rendered  rough. 

Even  when  the  ulcers  of  the  mucous  membrane  have  been  healed, 
the  membrane  itself  remains  much  thickened,  rough,  and  sometimes 
irregular  by  tubercular  growths ; and  the  perichondrium  of  the 
cartilages  is  thick,  soft,  and  easily  detached. 

In  this  state  the  diseased  action  is  liable  to  spread  to  tbe  carti- 
lages, rendering  them  thick,  painful,  and  sometimes  producing 
ulceration,  and  occasionally  imperfect  ossification. 

In  one  or  more  points  ulceration  takes  place  generally  in  oval 
patches,  which  spread  and  become  deep,  affecting  the  submucous 
tissue  and  the  perichondrium.  The  ulcers  which  were  previously  an 
effect,  become  now  a cause  of  inflammation,  and  obstinately  resist- 
ing all  tendency  to  heal,  continue  to  spread  with  chronic  inflamma- 
tion, and  give  rise  to  more  or  less  wasting  with  hectic  fever.  This 
constitutes  the  disease  described  under  the  name  of  laryngeal  con- 
sumption ; (^phthisis  laryngaea.)  (Cayol.) 

In  some  instances  suppuration  of  the  submucous  filamentous 
tissue  takes  place  previous  to  ulceration  of  the  membrane ; and 
though,  by  affecting  the  perichondrium  on  the  one  side,  and  the 
laryngeal  mucous  membrane  on  the  other,  it  may  cause  the  same 
chronic  process  as  that  now  described,  it  is  generally  a milder  and 
more  sanable  disease. 

In  others  it  spreads  to  the  cartilages,  and  by  inducing  ulceration 


574 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


or  death  of  these  bodies,  causes  an  insanahle  disease  speedily  fatal. 
In  Mr  Dyson’s  case,  in  which  the  epiglottis  and  upper  part  of  the 
trachea  were  ulcerated,  the  os  hyoides  became  carious,  and  was 
exfoliated  dead.* 

Of  both  acute  and  chronic  laryngitis,  it  is  a peculiar  character, 
that  death  often  takes  place  suddenly,  and  sometimes  when  not  ex- 
pected. 

The  causes  of  chronic  laryngitis  are  the  same  as  those  of  the  acute 
form  ; that  is,  exposure  to  cold,  previous  attacks  of  the  acute  form, 
and  extraordinary  efforts  of  the  voice  in  speaking,  crying,  or  shout- 
ing. One  cause,  however,  is  so  peculiar  that  it  deserves  mention. 
It  consists  in  the  use  of  mercury,  often  in  repeated  courses.  In 
almost  all  the  cases  of  chronic  laryngitis  which  have  come  under  my 
observation  during  tlie  course  of  twenty-five  years,  the  sufferers  had 
been  subjected  to  one  or  more  full  courses  of  mercurial  medicines, 
and  sometimes  to  several  repeated  courses.  The  effect  of  this  was 
to  render  all  the  mucous  surfaces  prone  to  irritation  and  inflamma- 
tion ; and  especially  where  these  surfaces  are  near  the  periosteum  or 
perichondrium.  The  cases  are  always  susceptible  of  alleviation  ; 
but  the  symptoms  invariably  recur,  showing  the  chronic  nature  of 
the  disorder,  and  the  firm  hold  which  it  takes  of  the  larynx. 

y.  Ulceration,  of  the  Laryngeal  and  Tracheal  membrane  in  phthisis. 
— In  persons  cut  off  by  tubercular  consumption,  minute  ulcers  of 
the  laryngeal  and  tracheal  membrane  are  not  unfrequent.  They 
vary  in  size,  and  are  irregular  in  shape ; but  in  general  they  ap- 
pear in  the  form  of  angular  or  oval  spots,  from  w’hich  the  mucous 
membrane  has  been  entirely  removed.  In  the  larynx  of  a young 
woman  in  my  collection,  I count  five  of  these  eroded  spots  affecting 
the  oval  shape,  none  of  more  extent  than  one  square  line,  and  one 
patch  evidently  formed  by  the  coalescence  of  two,  as  large  as  the 
section  of  a split  pea ; and  in  the  tracheal  membrane  of  the  same 
subject,  at  the  bronchial  bifurcations,  large  patches  of  the  same  de- 
scription are  visible.  In  the  latter  situation,  indeed,  this  destruc- 
tion is  more  common  and  more  extensive  than  in  any  other  point. 

The  most  frequent  site  of  ulcers  of  the  larynx,  according  to 
Louis,  is  the  junction  of  the  vocal  chords ; then  the  vocal  chords 
themselves ; and  lastly,  the  base  of  the  arytenoid  cartilages,  the 
upper  part  of  the  larynx  and  the  sacculi.  In  the  traehea  these 
ulcers  occupy  chiefly  the  posterior  part.  The  bronchial  mem- 
* Mem.  Med.  Society,  Vol.  TV. 


TRACHEO-BRONCHIAL  MUCOUS  MEMBRANE. 


575 


brane  is,  according  to  the  same  authority,  less  frequently  ul- 
cerated ; but  when  not  so,  it  is  almost  invariably  reddened. 

S.  Ulceration  of  the  Tracheal  Membrane  and  Cartilages. — This 
is  not  a very  frequent  lesion,  but  it  is  liable  to  take  place.  It  is 
seen  mostly  in  the  posterior  surface  of  the  trachea;  and  though 
probably  it  may  take  place  in  several  points,  yet  I have  never  seen 
more  than  one  or  at  most  two  ulcers,  one  generally  large.  No 
doubt  can  be  entertained  that  ulcers  of  this  kind  are  the  result  of 
inflammation  attacking  the  raucous  membrane  of  the  trachea ; but 
on  the  early  history  of  these  ulcers  we  possess  no  correct  informa- 
tion. The  following  details  will  convey  some  idea  of  the  appear- 
ance and  characters  of  these  ulcers. 

In  one  case,  taking  place  in  a man  of  about  48  or  50  years  of 
age,  the  individual  suflfered  much  from  constant  difficulty  of  deglu- 
tition, a sense  of  soreness  and  rawness  in  the  throat,  great  hoarse- 
ness, cough,  difficult  breathing,  and  scanty  expectoration  occasion- 
ally streaked  with  blood.  All  solids  and  fluids  caused  during  de- 
glutition much  suffering,  and  a feeling  of  impending  suffocation;  and 
the  patient  of  his  own  accord  I’equested  food  of  a semifluid  character. 
Even  this  was  swallowed  with  little  less  difficulty,  and  with  much  of 
the  gasping  and  suffocating  feeling.  Soon  after  death  took  place. 

The  laryngeal  mucous  membrane  was  red,  thickened,  and  co- 
vered with  a considerable  quantity  of  thick  puriform  mucus.  This 
was  abundant  in  the  sacculi  between  the  superior  and  inferior  vo- 
cal chords.  The  laryngeal  mucous  membrane  presented  abrasions 
and  ulcerations.  The  epiglottis  was  thickened,  reddened,  rigid,  and 
ulcerated  at  its  apex.  The  tracheal  membrane  was  very  much  red- 
dened, and  as  if  roughened.  About  one  inch  and  a half  below  the 
cricoid  cartilage,  immediately  above  the  bifurcation  of  the  trachea 
on  the  posterior  surface,  was  first  one  elliptical  ulcer,  then  another 
smaller,  both  with  the  long  axis  in  the  long  direction  of  the  wind- 
pipe. The  first  ulcer  was  about  three-fourths  of  one  inch  or  nearly 
one  inch  long;  the  other  about  one-fourth  of  an  inch  long.  Both  were 
formed  by  total  destruction  of  the  mucous  membrane  and  part  of  the 
sub-mucous  tissue  ; and  the  base  of  the  ulcer  was  formed  by  part  of 
that  connecting  the  windpipe  to  the  oesophagus.  The  edges  of  both 
were  ulcerated,  irregular,  and  ragged,  and  consisted  of  jagged  points; 
but  this  was  caused  by  the  projection  of  the  extremities  of  the  cartila- 
ginous rings,  which  were  cut  right  across,  and  being  less  destroyed 
than  the  connecting  mucous  membrane,  left  between  them  hollow 
spaces.  The  cartilages  also  projected  into  the  interior  of  the  trachea, 


576 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


being  no  longer  held  down  by  the  raucous  membrane  uniting  with 
those  of  the  opposite  side. 

This  man,  like  many  persons  under  laryngeal  disease,  had  been 
previously  subjected  to  several  courses  of  mercurial  medicines. 

In  another  case  I saw  an  ulcer  of  the  trachea  take  place  under 
j)eculiar  circumstances. 

A female  between  40  and  45  years  of  age  was  affected  with 
chronic  laryngitis  ; and  over  this  was  super-induced  an  acute  at- 
tack so  intense,  that  immediate  suffocation  was  threatened.  For 
relieving  her  sufferings  and  averting  the  fatal  termination,  it  was 
deemed  necessary  to  perform  the  operation  of  laryngotomy  or  tra- 
cheotomy. This  was  accordingly  done  with  very  beneficial  results, 
the  breathing  being  much  relieved,  and  the  urgent  symptoms  of 
suffocation  in  the  meantime  removed.  The  tube  was  inserted  and 
kept  in  the  wound  for  about  three  weeks  or  longer,  being  with- 
drawn only  to  cleanse  the  wound,  and  remove  mucus  and  purulent 
matter. 

About  this  time  it  was  recommended  to  the  patient  to  try  to 
breathe  without  the  tube ; but  she  found  that  this  was  impracticable. 
Meanwhile  the  same  course  was  pursued  for  about  three  weeks  | 
longer,  during  which  the  patient  did  not  appear  to  be  recovering 
the  power  of  breathing  through  the  larynx.  Uneasiness  and  sore- 
ness were  felt  in  the  windpipe;  and  this  it  was  natural  to  ascribe 
to  the  wound.  After  some  days  longer  of  struggling,  irritation, 
distress  and  agony,  the  patient  suddenly  expired. 

The  laryngeal  membrane  was  red,  thickened,  rough,  and  irregu- 
lar ; and  when  the  abundant  mucus  was  removed,  minute  ab- 
rasions were  observed.  The  chords,  both  superior  and  inferior,  were 
thickened  and  swelled.  The  wound  was  healthy  and  granulating, 
though  slowly  and  irregularly.  At  the  posterior  surface  of  the 
trachea,  about  one  inch  and  a-half  below  the  cricoid  cartilage,  a 
large  elliptical  ulcerated  destruction  of  the  mucous  membrane  had 
taken  place.  The  edges  and  outlines  of  this  were  irregular.  The 
long  diameter  corresponded  to  the  axis  of  the  trachea.  In  some 
parts  this  ulcer  was  deep,  almost  proceeding  through  to  the  ceso-  | 
phagus ; in  others  it  was  more  superficial.  The  ulcerated  extremi- 
ties of  the  cartilaginous  rings  were,  however,  exposed  in  the  same 
manner,  and  prominent,  as  in  the  case  last  mentioned;  and  gave 
the  ulcer  the  same  ragged  appearance. 

This  large  ulcer  corresponded  so  accurately  to  the  extremity  of 


TRACHEO-BRONCHIAL  MUCOUS  MEMBRANE. 


57? 


the  tube,  which  was  kept  in  the  wound,  that  it  seemed  impossible 
to  doubt  that  it  had  been  produced  by  the  constant  pressure  and 
irritation  of  the  tube  on  the  posterior  surface  of  the  windpipe.  I 
am  aware  that  it  may  be  said,  that  if  the  tube  were  so  placed,  it 
was  improperly  placed ; and  not  only  must  have  produced  irritation 
in  the  windpipe,  but  could  not  have  acted  as  a tube  to  convey  air 
into  the  windpipe  and  out  again  in  the  actions  of  respiration.  It  is 
also  possible  that  some  ulcer  or  ulceration  may  have  existed  there 
previously,  and  may  have  been  associated,  as  is  often  the  case,  with 
chronic  disease  of  the  larynx.  To  this  it  is  not  necessary  to  give 
any  other  answer  than  merely  stating  the  facts  of  the  case. 

This  patient  had  been  subjected  to  the  use  of  mercury  in  full 
courses,  more  than  once ; and  of  this  the  laryngeal  aflPection  was 
the  result. 

§ 2.  «.  Croup  (^Bronchiasis  albuminosa)  may  be  defined  to  be 
inflammation  of  the  tracheo-bronchial  mucous  membrane,  termi- 
nating in  sero-albuminous  exudation.  The  points  deserving  atten- 
tion in  the  pathology  of  this  disease,  are,  Ist^  the  fact  of  inflamma- 
tion ; 2d,  the  extent  of  the  process  ; and,  2>dly,  its  effects.  The  in- 
flamed state  of  the  tracheo-bronchial  membrane  is  estabb’shed  be- 
yond doubt.  Home  observed  that  it  was  redder  than  natural  when 
the  concrete  covering  is  detached;  Rumsey  recognized  manifest  traces 
of  inflammation ; in  Cheyne’s  cases  the  vessels  of  the  membrane 
were  large,  distinct,  and  sometimes  numerous,  (9th.)  The  same 
was  seen  by  Albers,  Jurine,  and  Bretonneau.  In  short,  whether 
the  membranous  exudation  be  present  or  absent,  the  tracheo- 
bronchial membrane  is  always  more  or  less  red,  bloodshot,  vil- 
lous, and  swollen ; and  puriform  fluid  oozes  from  the  bronchial 
tubes. 

This  inflammation  is  seated  in  the  tracheo-bronchial  membrane 
solely.  It  begins  immediately  below  the  cricoid  cartilage,  and  ex- 
tends along  the  tube  into  the  bronchi  and  bronchial  membrane. 
It  is  less  frequently  observed  to  affect  the  laryngeal  membrane ; and 
when  it  does  so,  this  is  to  be  viewed  as  a complication  not  essential 
to  genuine  croup.  It  may,  nevertheless,  in  extreme  cases,  affect 
the  pharynx,  larynx,  and  trachea,  covering  their  surface  with  a false 
membranous  exudation.  The  disease,  from  this  circumstance,  re- 
ceives the  name  of  Diphtheritis, 

The  effect  of  this  inflammation  is  to  produce  from  the  surface  of 
the  membrane  a fluid  or  semifluid  secretion,  which  soon  undergoes 

o 0 


578 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


coagulation  after  exposure  to  the  aii’.  In  the  upper  part  of  the 
trachea  this  substance  is  firm  and  in  the  form  of  a tubular  mem- 
brane moulded  on  the  canal ; below  and  in  the  bronchial  divisions 
it  is  less  firm  ; in  the  tubes  it  is  completely  fluid.*  (Home,  Cheyne, 
Bretonneau.)  The  nature  of  this  morbid  exudation  has  been  a 
matter  of  ambiguity.  Home,  who  remarked  that  the  tubular  mem- 
brane when  complete  is  tough  and  thick,  might  be  soaked  in  water 
for  days  without  dissolving,  that  it  does  not  adhere  to  the  wind- 
pipe, as  there  is  always  fluid  matter  beneath  it,  and  that  beyond  it, 
the  windpipe,  bronchial  tubes,  and  pulmonic  vesicles,  are  covered 
by  pus  or  purulent  mucus,  thought  it  of  the  nature  of  thickened 
mucus.  In  one  case  Rumsey  calls  it  viscid  mucus  or  phlegm ; in 
others  he  likens  it  to  the  buffy  coat.  Field  regards  it  as  coagulable 
lymph ; Cheyne,  with  some  confusion,  compares  it  to  the  exuda- 
tion of  the  inflamed  pleura  or  peritonaeum,  and  accounts  it  thickened 
puriform  fluid ; while  by  Pinel  and  most  of  the  recent  authorities, 
it  is  identified  with  albuminous  exudation.  According  to  the  in- 
vestigation of  its  chemical  properties  by  Schwilgue,  Maunoir  and 
Peschier,  and  Jurine,  it  appears  to  contain  albumen  in  various  pro- 
portions, and  to  owe  to  this  principle  its  tenacity  and  firmness. 
Bretonneau,  in  particular,  endeavours  to  establish  a distinction 
between  the  ti’acheo-bronchial  exudation,  the  albuminous  concre- 
tions of  serous  membranes,  and  the  buffy  coat,  but  without  success.f 
It  may  be  inferred,  therefore,  that  this  substance,  without  being 
either  wholly  coagulable  lymph,  or  thickened  mucus,  or  dried  pu- 
rulent matter,  is  a morbid  product  secreted  from  the  tracheo-bron- 
chial  mucous  surface,  in  a semifluid  form,  and  undergoing,  in  con- 
sequence of  the  presence  of  albuminous  or  album  ino-gelatinous 
matter,  coagulation,  as  it  is  more  freely  exposed  to  air. 

Death  is  produced  in  this  disease  chiefly  by  the  albuminous  fluid 
in  the  bronchial  tubes  and  vesicles  excluding  the  air  from  the  pul- 
monary membrane. 

j3.  Bronchiasis  albuminosa  adultorum.  Polypose  injlammation  of 
the  trachea. — Not  very  dissimilar  is  that  morbid  state  of  the  tracheo- 
bronchial membrane,  in  which  a membranous  concretion,  moulded 
on  the  tube,  is,  from  time  to  time,  brought  up  by  coughing  either 

■*  “We  can  even  demonstrate,”  says  Cheyne,  “ the  adventitious  membrane  degene- 
rating into  the  puriform  fluid,  and  again  gaining  consistence  in  different  parts  of  thc- 
same  membrane.” 

t Des  Inflammations  du  Tissu  Muqueux,  et  en  particulier  de  la  Diphtherite,  &c. 
Paris,  1826.  P.  293. 


TRACHEO-BRONCHIAL  MUCOUS  MEMBRANE. 


579 


in  fragments  or  entire.  Instances  of  this  disease,  which  is  not  com- 
mon, were  first  observed  by  T.  Bartholine,*  N.  Tulpius,t  Ruysch,:!; 
Clarke,§  Lister,  Cheselden,  Bussiere,||  Samber,ir  F.  Nicholls,** 
Warren,f|  John  Andrew  Murray,  Callisen,  §§  Baillie,  and 
Laennec. 

The  mode  of  their  formation  is  not  established  without  ambiguity. 
In  many  instances  they  are  the  result  of  a modification  of  the  in- 
flammatory process.  In  some,  however,  in  which  they  are  connected 
with  bronchial  or  pulmonary  hemorrhage,  they  appear  to  be  formed 
by  the  coagulation  of  blood  not  discharged  at  the  time  of  hemor- 
rhage. 

§ 3.  Bronchial Injiammation,  acute,  and  chronic.  Bronchiasis  puri- 
formis ; Bronchitis. — Bronchitis  may  be  distinguished  into  two  varie- 
ties, according  to  the  portions  of  the  air-tubes  which  it  affects.  The 
disease  may  be  confined  chiefly,  if  not  solely,  to  the  large  and  middle- 
sized  bronchial  tubes,  in  short,  where  the  mucous  membrane  lines 
tubes,  properly  so  called ; or  it  may  either,  with  or  without  affec- 
tion of  these,  be  seated  principally  in  the  terminal  ends  or  vesicles 
where  the  membrane  is  more  delicate,  and  the  tubes  are  much 
smaller.  In  the  former  case,  the  impediment  to  respiration  is  much 
less  considerable  than  in  the  latter,  in  which,  from  their  small  size, 
any  thickening  or  new  secretion  produces  most  serious  and  alarm- 
ing labour  in  breathing,  with  great  anxiety  and  distress.  The  former 
may  be  termed  tubular  bronchitis,  the  latter  vesicular  bronchitis, 
or  bronchitis  of  the  vesicles,  or  of  the  small  bronchial  tubes  and 
terminal  ends  of  the  small  bronchial  tubes. 

I am  aware  that  the  latter  is  by  some  believed  to  constitute  pneu- 
monia or  inflammation  of  the  lungs ; and,  in  point  of  fact,  in  all 
cases  of  pneumonia  or  inflammation  of  the  substance  of  the  lungs, 
there  is  a considerable  affection  of  the  terminal  ends  of  the  bronchi ; 
and  in  cases  of  affection  of  the  vesicles  on  the  other  hand,  there  is , 
sooner  or  later  some  affection  of  the  pulmonic  tissue.  In  short, 
the  two  diseases  pass  into  each  other,  and  in  most  cases  co-exist. 

* Centur.  iii.  Hist.  98.  -t  Obs.  Lib.  ii.  Obs.  7. 

J Epistola  Anatomica,  VI.  p.  9 et  11.  Amstelodami,  1659.  Op.  Om.  Tom.  II. 

§ Phil.  Trans.  No.  235,  p.  779  and  780.  Vol.  XIX. 

II  Ibid.  No.  263,  p.  545.  Vol.  XXII. 

H Ibid.  No.  398,  p.  262.  **  Ib.  No.  419,  p.  123. 

-ti"  Transactions  of  College  of  Physicians,  Vol.  I.  p.  407. 

Commentatio  de  Poly  pis  Bronchioram.  Goettingas,  1773.  Opnscula,  Vol.  I.  1785. 
VI.  p.  255. 

§§  Observatio  de  Concretione  Polyposa,  Cava,  Ramosa,  tussi  rejecta.  Acta  Societatis 
MedicEe  Havniensis,  Vol.  I.  Ha^'ni£e,  1777.  Art.  IV.  p.  76. 


580 


GENERAL  AND  PATHOLOGICAL  ANATOMY, 


This,  however,  is  no  reason  for  confounding  these  affections  in  a 
work  like  the  present,  in  which  morbid  processes  are  considered  in 
an  analytical  manner,  according  to  the  individual  elementary  tex- 
tures which  they  affect.  This  analytical  method  leads  to  no  error ; 
and  it  enables  the  pathologist  more  clearly  to  understand  the  cha- 
racteristic differences  of  closely  allied  diseases. 

a.  Tubular  bronchitis.  Bronchitis  affecting  the  large  and  middle- 
sized  air-tubes. — In  tubular  bronchitis,  then,  tbe  inflammatory  disorder 
is  very  much  confined  to  the  large  and  middle  sized  bronchial  tubes ; 
and  as  this  disease  as  a primary  affection  is  not  often  fatal,  and  is 
chiefly  so  by  recurring  frequently,  or  by  the  morbid  action  extending 
to  the  small  tubes  and  the  vesicles,  itis  not  possible  to  speak  accurately 
of  its  anatomical  characters  as  an  isolated  affection.  When  in  these 
circumstances  the  membrane  isexamined,it  is  found  brown-coloured, 
sometimes  dark  red,  rough,  and  swelled,  with  more  or  less  contrac- 
tion of  the  area  of  the  bronchial  tubes.  These  tubes  are  lined  by 
viscid  jelly-like  mucus,  streaked  with  blood  or  embrowned.  In 
some  instances  tbe  mucus  is  puriform,  yet  adheres  to  the  mem- 
brane. 

This  form  of  bronchitis  takes  place  not  only  in  catarrh,  but  in 
the  course  of  continued  fever,  of  typhus  fever,  in  measles,  in  scarlet 
fever,  and  in  small-pox.  It  is  also  an  invariable  accompaniment  of 
tubercular  destruction  in  consumption,  and  is  frequent  in  cases  of 
diseased  heart,  especially  hypertrophy  and  valvular  disease. 

By  frequent  recurrence  it  is  liable  to  produce  symptoms  of 
asthma,  or  to  pass  into  chronic  catarrh,  with  dyspnoea,  or  into  dry 
catarrh.  It  then  gives  rise  to  winter  cough. 

Tubular  bronchitis  may  terminate  in  health  by  the  gradual  sub- 
sidence of  the  inflammation  ; in  vesicular  bronchitis  by  extending 
to  the  vesicular  mucous  membrane;  in  thickening  of  the  tubular 
membrane  and  contraction  of  the  tube,  {stenochoria  bronchorum,) 
causing  symptoms  of  asthma,  breathlessness,  and  more  or  less  chro- 
nic cough,  aggravated  especially  in  the  winter,  during  cold  weather, 
and  on  the  accession  of  any  slight  cold  ; in  emphysema  of  the  lungs 
with  breathlessness ; in  oedema  of  the  lungs ; in  serous  effusion 
within  \he pleura  {liydropleura ; hy dr othor ax general  dropsy. 

The  formidable  terminations  last  mentioned  seldom  take 
place  until  the  disease  has  recurred  several  times;  and  as  it  i.^ 
alw'ays  liable  to  recur  after  the  first  attack,  it  necessarily  renders 
tbe  bronchial  tubes  less  fit  for  the  pui'pose  of  admitting  air  to 
the  vesicles.  In  the  bodies  of  those  destroyed  under  this  ad- 


TRACHEO-BRONCHIAL  MUCOUS  MEMBRANE. 


581 


vanced  stage  of  the  disease  the  following  appearances  are  recog- 
nised. 

1.  Collapse  of  the  lungs,  on  opening  the  ehest,  either  imperfect 
or  none  ; the  lungs  inelastic,  doughy,  and  gorged  with  venous 
blood ; sometimes  oedematous,  sometimes  slightly  solidified.  2 . 
The  bronchi  and  large  bronchial  tubes  containing  a considerable 
quantity  of  viscid,  opaque,  tenacious  mucus  adhering  firmly  to  the 
membrane ; the  membrane  itself  in  the  bronchi  and  large  tubes  red- 
dened, rough,  in  some  parts  swelled,  and  of  a colour  more  or  less 
brown.  3.  Several  of  the  bronchial  tubes  present  portions  in  which 
the  area  of  their  canal  is  more  or  less,  sometimes  considerably,  con- 
tracted, forming  a degree  of  bronchial  stricture.  4,  Parts  of  the 
lungs,  especially  near  their  margin,  present  air  in  their  filamentous 
tissue,  and  sometimes  bladders  of  air,  forming  emphysema  of  the 
lungs.  5.  In  some  instances  a few  of  the  bronchial  tubes,  especially 
towards  the  lower  part  of  the  lung,  may  be  dilated  to  a gi’eater 
capacity  than  natural.  6.  In  certain  cases  they  are  narrowed,  or 
altogether  closed  and  obliterated. 

b.  Vesicular  Bronchitis.  Injiammatio  Vesicular um.—lx\  the 
second  variety,  either  w'ith  or  without  the  affection  of  the  membrane 
of  the  large  and  middle-sized  tubes,  inflammation  attacks  the 
pulmonic  or  vesicular  division  of  the  bronchial  mucous  mem- 
brane. 

The  pathology  of  this  disease,  though  understood  by  Mor- 
gagni, De  Haen,  and  Stoll,  has  been  more  fully  illustrated  by 
the  researches  of  Chevalier,  Badham,  Abercrombie,  Hastings,  and 
Laennec.  Dissections  of  persons  cut  off  in  different  stages  of  the 
disease  show  that  the  bronchial  membrane  is  much  reddened  and 
injected,  villous  or  pulpy,  and  thickened  or  swelled.  As  the  disease 
proceeds,  it  discharges  viscid  puriform  mucus,  or  muco-purulent 
fluid,  which  fills  the  air-cells  or  vesicles,  and  prevents  the  lungs 
from  collapsing  when  the  chest  is  opened.  The  tracheal  membrane 
may  be  reddened  or  traversed  by  arborescent  red  lines ; and  though 
the  bronchial  membrane  is  in  general  entire,  in  some  instances 
small  ulcerated  breaches  are  observed  in  various  parts. 

In  the  chronic  form,  the  membrane,  though  red  and  villous,  is 
rarely  so  much  swelled  as  in  the  acute  disease ; but  minute  ulcers 
or  patches  of  ulceration'  are  more  common. 

The  effect  of  this  process  in  the  bronchial  membrane  is  to  aug- 
ment the  quantity  and  change  the  quality  of  the  fluid  secreted  in 
the  natural  state.  At  the  commencement  of  the  process,  the  bluish. 


582 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


semitransparent,  and  particled  mucus  of  health  is  mixed  with  muci- 
laginous, semitransparent,  and  grayish  fluid,  not  unlike  white  of 
egg,  which  is  secreted  in  considerable  quantity.  As  the  process 
advances,  it  becomes  thicker,  more  viscid  and  opaque,  and  sinks  in 
water;  and  when  fully  established,  this  viscid  mucus  is  either 
mingled  with,  or  converted  into  yellowish  opaque  fluid,  which  can- 
not be  distinguished  from  purulent  matter,  and  which  is  generally 
more  or  less  streaked  with  blood.  These  changes  may  be  effected 
without  breach  of  continuity  or  ulceration  of  the  membrane.  This 
fact,  which  was  first  established  by  De  Haen,*  has  since  been  fully 
confirmed  by  Willan,f  Badham,J  George  Pearson,§  and  Hastings. || 
The  process  of  suppurative  secretion  is  attended  with  hectic  fever 
and  wasting. 

Though  ulcers,  however,  are  not  essential  to  chronic  inflammation 
of  the  bronchial  membrane,  they  may  occur,  and  are  most  common 
in  the  lungs  of  those  whose  occupation  exposes  them  to  inhalation 
of  irritating  mechanical  powders.  Such,  for  example,  has  dissec- 
tion shown  to  be  the  state  of  the  bronchial  membrane  in  stone- 
cutters,^ glass- grinders,  needle-grinders,  and  leather-dressers. 

c.  Pustular  Inflammation, — On  the  nature  of  a form  of  ulcer  con- 
siderably different  we  have  less  certain  information.  In  several 
cases  of  bronchial  disease,  the  membrane  becomes  the  seat  of  nume- 
rous minute  eminences,  which,  as  they  may  be  traced  through  the 
stages  of  inflammation,  suppuration,  and  ulceration,  maybe  regarded 
as  pustules  of  the  pulmonic  mucous  membrane.  The  ulcers  thus 
formed  are  in  general  round  or  oval,  rarely  irregular,  with  margin 
slightly  raised,  and  surrounded  by  a red  circle,  (areoZa,)  more  or 
less  distinct.  The  matter  expectorated  consists  of  purulent  fluid, 
streaked  with  blood,  and  mingled  with  a considerable  proportion  of 
dense  mucus.  The  analogy  between  this  and  certain  ulcers  of  the 
intestinal  raucous  membrane  is  obvious.  It  gives  rise  to  wasting 
and  hectic  fever. 

d.  Induration,!  Consolidation, — When  chronic  inflammation  sub- 
sists long,  the  inflammatory  action  extends  to  the  submucous  fila- 
mentous tissue,  which  unites  the  bronchial  tubes  and  vessels  to  the 
serous  membrane  of  the  lungs — the  parenchymatous  or  cellular  tissue 

* Rationis  Meclendi,  I.  xi.  p.  60.  t Reports,  1796,  20th  March. 

+ Observations  on  the  Inflammatory  Affections  of  the  Mucous  Membrane  of  the 
Bronchiee,  &c.  pp.  48 — 76. 

§ Phil.  Trans.  180.9,  Part  ii.  p.  315 — 321. 

II  Treatise  on  Inflammation  of  the  Mucous  Membrane,  &c. 

K Johnstone  of  Worcester,  Mem.  Med.  Society. 

3 


TRACHEO-BEONCHIAL  JIUCOUS  MEMBRANE. 


583 


of  the  older  anatomists.  Of  this  the  first  effect  is  redness,  with  vas- 
cular injection  of  the  submucous  tissue  (infarctio.)  As  the  morbid 
state  of  the  blood-vessels  continues  or  increases,  sero-albuminous 
fluid  is  effused  into  its  interstices ; the  part  loses  its  natural  softness 
and  elasticity ; and  as  the  process  extends,  the  lung  loses  the  spongy 
lightness  which  depends  on  permeability  of  its  vesicles.  In  a lung 
in  which  the  chronic  inflammation  of  the  submucous  tissue  has 
subsisted  for  some  time,  the  following  phenomena  are  recognized  : — 
Isf,  On  opening  the  chest  and  admitting  the  air,  though  there  are 
no  adhesions,  the  lung  collapses  imperfectly  or  not  at  all ; 2d,  The 
pulmonic  tissue  surrounding  a portion  of  inflamed  membrane  be- 
comes hard  and  dense,  and  floats  deep  or  sinks  in  water ; 3d,  De- 
prived of  its  elasticity  and  compressibility,  it  cannot  be  inflated, 
does  not  crepitate,  and  resembles  a portion  of  solid  flesh.  In  such 
circumstances  bronchial  inflammation  is  complicated  with  pneu- 
monia. 

e.  Bronchitis  from  the  presence  of  foreign  bodies. — Bronchitis 
alienorum. — A variety  of  chronic  bronchial  inflammation,  important 
from  its  close  resemblance  to  consumption,  is  that  occasioned  by  the 
presence  of  foreign  bodies  which  have  dropped  accidentally  into  the 
windpipe.  Of  this  species  of  disease  many  cases  are  recorded,  as 
having  occurred  to  diflPerent  observers  ; and  the  facts  of  these  cases 
show  at  once  the  influence  of  the  cause  alleged  iti  producing  chronic, 
bronchial,  and  occasionally  pulmonary  inflammation,  closely  imitating 
pulmonary  consumption,  and  the  great  efi’orts  made  by  the  system 
in  striving  to  get  rid  of  a source  of  great  and  possibly  fatal  irrita- 
tion. 

Foreign  bodies  which  drop  into  the  air  passages  may  produce 
one  of  two  effects.  First,  a foreign  body  dropping  into  the  larynx 
may,  by  fixing  itself  in  the  ventricles,  or  in  the  rima  glottidis,  cause 
immediate  suffocation.  This  result  will  depend  on  its  shape,  or  its 
consistence,  and  its  size.  Thus,  portions  of  food  masticated,  or 
imperfectly  masticated,  are  occasionally  observed  to  produce  suffo- 
cation and  immediate  death.  Or,  secondly,  a foreign  body  may 
drop  into  the  larynx,  and  by  passing  entirely  through  the  rima 
glottidis,  may  get  into  the  windpipe  and  one  of  the  bronchial  tubes, 
and  stopping  there,  cause  great  irritation  and  inflammation  of  the 
parts,  indicated  by  frequent,  urgent,  and  distressing  cough ; fits  of 
difiicult  breathing ; expectoration  of  dense,  puriform  mucus,  often 
with  blood  ; and  wasting  of  the  flesh  and  strength  of  the  individual, 
nearly  in  the  same  manner  and  to  the  same  extent  as  in  pulmo- 


584 


GENERAL  AND  PATHOLOGICAL  ANATOMY, 


nary  consumption.  It  is,  indeed,  remarkable  that,  in  all  the  re- 
corded cases,  the  symptoms  thus  produced  have  home  so  close  a 
resemblance  to  'phthisis,  that  they  have  in  most  instances  been  con- 
sidered as  examples  of  consumptive  disease,  and  by  several  they 
are  described  as  such. 

The  bodies  which  have  in  this  manner  been  known  to  drop  into 
the  windpipe  are  various ; beans,*  nuts,t  walnuts, | cherry  stones,§ 
plumb  stones, II  an  iron  nail,^  a leaden  shot,**  teeth,  natural  and 
artificial, tt  ears  of  grass,J|,  fragments  of  bones,  a fragment  of  nut- 
meg,§§  pieces  of  money,  ||  ||  and  similar  substances.  Of  various  pointed 
and  well  authenticated  examples  of  this  accident  and  its  effects,  I 
published  in  1834  a collection,  with  the  view  of  showing  the  true 
nature  and  effects  of  the  lesion  and  its  degree  of  frequency ; and 
the  most  instructive  mode  of  presenting  the  results  of  this  series  of 
cases,  I believe  to  be  placing  them  in  the  tabular  form  which  is  here 
subjoined.  This  list  I might  have  enlarged  more  than  I have  done. 
But  I believe  that  the  present  table  gives  a sufficient  number  of 
well  established  and  accurately  detailed  facts  to  enable  the  reader 
to  form  just  ideas  on  the  nature  of  the  disorder,  and  to  compare 
the  facts  with  the  inferences  deduced. 

* Boussier  de  la  Bouchardiere.  Journal  de  Medecine,  xlv.  p.  267.  Guincourt  in 
Journal  de  Medecine,  continue,  xii.  p.  44. 

Allard,  Joui'nal  de  Physique,  T.  li. 

Klein  Chirurgische  Bemerkungen,  p.  168.  Vicq  D’Azyr  Memoires  de  la  Societe 
de  Medecine,  Vol.  IV.  Chir.  N.  3,  fatal  on  6th  day. 

+ Ephemerides  Naturae  Curiosorum,  Dec.  ii.  Ann.  i.  Obs.  144. 

Ephemerides  Naturae  Curiosorum,  Decad.  iii.  Ann,  iii.  Obs.  18.  Dr  Scott’s  case  in 
Dr  Craigie’s  Memou'. 

§ Ephemerides  Naturae  Curiosorum,  Dec.  ii.  Ann.  x.  Obser.  66.  Desault  Oeuvres 
Chirurgicales,  2ieme  Tome. 

1|  Deschamps  in  Journal  de  Medecine,  continue,  ii.  p.  555. 

U Morton  Phthisiologia,  Lib.  iii.  cap.  vi.  p.  143.  London,  168ft. 

Howship’s  Practical  Observations  in  Medicine  and  Morbid  Anatomy,  p.  222. 

Dr  Craigie’s  Case.  See  page  590. 

**  Birch  History  of  the  Royal  Society,  Tome  III.  Robert  Hooke,  Collections. 
Transactions  of  a Society,  Vol.  III.  Lond.  1812. 

ft  Cases  in  Memoir  by  Dr  Craigie.  Edin.  Medical  and  Surgical  Journal,  Vol, 
XLII.  p.  103.  Edin.  1834. 

Histoire  et  Memoires  de  Thoulouse,  II.,  ejected  by  abscess  in  the  side  ; phthisical 
symptoms  ; and  Dr  Donaldson’s  case  in  Edinburgh  Medical  and  Surgical  Journal,  Vol. 
XLII.  p.  102.  Edin.  1834. 

§§  Borelli  P.  Observationes  Medico-Pbysicae.  Cent.  IV.  Obs.  63. 

Ill  De  la  Martiniere  dans  Memoires  de  I’Academie  de  la  Chirurgie,  Tome  V.  Rc- 
?nained  five  years.  Mr  Key’s  Case  ; and  the  Case  of  Sir  I.  Brunell  by  Sir  B.  Brodie, 
W edico-Chirurgical  Transactions. 


i 


TRACHEO-BRONCHIAL  MUCOUS  MEMBRANE. 


589 


This  tabular  statement  contains  24  cases,  among  which  eight  ter- 
minated in  death,  five  of  these  being  cases  in  which  the  body  was 
not  ejected. 

In  each  of  the  cases  terminating  favourably  the  usual  symptoms 
of  chronic,  bronchial,  and  even  of  pulmonary  inflammation  were 
induced ; and  purulent  expectoration  with  occasional  hemoptysis, 
and  hectic  and  great  wasting,  threatened  certain  death.  In  each, 
however,  after  a lapse  of  weeks,  months,  or  years,  the  foreign  body 
was  rejected  by  coughing  when  least  expected,  and  recovery  even- 
tually took  place.  Though  this  favourable  issue  prevents  the  pa- 
thologist from  ascertaining  with  certainty  the  exact  nature  and  ex- 
tent of  the  lesion,  it  is  reasonable,  from  the  facts  disclosed  by  in- 
spection of  the  fatal  cases,  to  infer  that  the  bronchial  membrane 
certainly,  and  probably  the  pulmonic  tissue,  were  maintained  in  a 
state  of  chronic  inflammation  during  the  presence  of  the  foreign 
body. 

Among  the  fatal  cases  are  six  in  which  the  state  of  the  parts 
was  inspected  after  death  ; and  from  these  we  learn  several  instruc- 
tive facts. 

] . In  the  case  given  by  Morton,  the  patient,  after  the  first  irri- 
tative symptoms  were  over,  suffered  so  little  inconvenience,  and  was 
apparently  so  well,  that  for  several  months  he  pursued  hisbusiness  or 
profession  as  a whitewasher,  and  entered  into  the  matrimonial  state. 
On  the  evening  of  the  day  of  marriage,  however,  he  was  attacked 
with  most  acute  pain  of  the  breast  and  side,  difficult  breathing,  and 
frequent  dry  cough,  so  urgent  that  he  could  neither  lie  in  bed 
nor  sleep.  Fever  followed ; and,  notwithstanding  the  active  and 
judicious  use  of  approved  remedies,  the  symptoms  of  pulmonic  in- 
flammation  and  suppuration  with  hectic  were  established,  and  death 
took  place  at  the  end  of  five  weeks. 

The  three  nails  were  found  a little  below  the  division  of  the 
bronchi,  buried,  as  it  were,  in  a bed  of  purulent  matter,  which  was 
also  spreading  gradually  through  the  lungs.  The  cavity  of  the 
pleura  contained  about  six  pints  of  purulent  matter. 

2.  In  the  case  of  the  engraver  recorded  by  De  la  Martiniere  and 
Louis,  the  left  lung  was  sound.  The  right  lung  was  almost  entirely 
destroyed  by  suppuration.  The  right  cavity  of  the  chest  was  filled 
with  purulent  matter ; and  the  Louis  d’or  was  found  placed  perpen- 
dicularly at  the  upper  part  of  the  right  lung  at  the  first  bifurcation 
of  the  bronchus  on  this  side. 


588 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


In  this  case  the  piece  of  money  had  produced  inflammation,  first 
in  tlie  large  hronchial  tubes,  where  it  was  fixed,  then  in  the  lung, 
and  afterwards  in  the  pleura.* 

3.  In  the  case  communicated  hy  M.Lenglet  to  M.  De  laMartiniere 
in  which  a splinter  of  bone  triangular  in  shape,  with  sharp  angles 
and  cutting  edges,  one  side  9 lines  long,  had  remained  10  months 
in  the  bronchial  tubes,  the  right  lung  was  natural,  hut  the  left  in  a 
state  of  putrefaction.  About  four  inches  below  the  bifurcation  on 
the  left  side  was  a preternatural  cavity  of  the  capacity  of  a large 
nutmeg ; and  in  this  cavity  the  bone  had  been  lodged.f 

4.  In  the  case  given  by  Dr  Milroy,  in  the  centre  of  the  right 
lung  was  found  a large  abscess  containing  about  twenty  ounces  of 
purulent  matter,  of  reddish-brown  colour,  and  fetid  odour.  The 
piece  of  chicken  bone,  which  was  light  and  porous,  weighing  only 
six  grains,  lay  in  the  upper  part  of  the  right  bronchus^  close  to  the 
bifurcation  of  the  trachea.  This  tube  (I  suppose  the  right  hron- 
elms)  communicated  with  the  upper  part  of  the  abscess. 

5.  In  the  case  given  by  Schroeder,  the  right  lung  was  occupied 
by  several  tubercles,  among  which  was  a vomica  in  the  middle 
lobe,  filled  not  with  purulent  matter  but  with  black  gore.  The 
left  lung  contained  everywhere  tubercles  and  several  small  vomicce, 
and  in  the  left  bronchus  about  one  inch  from  the  bifurcation  of  the 
trachea  was  a splinter  of  hone  covered  with  black  viscid  mucus. 
This  bone  was  rough,  and  its  angles  had  so  completely  penetrated 
the  bronchial  mucous  membrane,  that  it  could  be  moved  neither 
upwards  nor  downward. 

6.  In  the  case  given  by  Dr  Houston,  the  broken  tooth  was  found 
lying  in  the  right  hronchial  tube  about  one  inch  beyond  its  com- 
mencement, with  the  fangs  directed  towards  the  lung,  and  the 
broken  surface  of  the  crown  towards  the  larynx.  It  lay  loose 
and  unattached,  and  when  caught  between  the  points  of  the  scissors 
was  readily  removed.  The  broken  surface  fitted  accurately  to  that 
of  the  crown  as  presented  by  the  patient  to  Dr  Houston. 

The  right  lung  adhered  to  the  -pleura  costalis  everywhere  except 
behind,  where  bloody  fluid  lay  between  the  pleurae.  The  adhesions 
were  soft  and  easily  broken ; the  right  pulmonic  pleura  was  livid. 
The  substance  of  the  right  lung  was  dense  and  indurated  through- 

• Memoires  tie  I’Academie  Royale  de  Chirurgie,  Tome  V.,  p.  528-531.  Paris, 
1774. 

t Ibid.  p.  533.  Paris,  1774. 


TRACHEO-BRONCHIAL  JIUCOUS  MEMBRANE. 


589 


out;  and  lacerable;  much  loaded  with  blood  and  serum.  The 
left  pleurae  adhered  universally ; and  the  left  lung,  though  less 
heavy  and  gorged,  was  everywhere  reddened  and  ejected. 

The  mucous  membrane  from  the  larynx  to  the  smallest  branches 
of  the  bronchial  tubes  in  both  lungs  was  swelled,  softened,  and  of 
a deep  red  colour ; and  the  bronchial  tubes  were  filled  with  muco- 
purulent fluid  round  the  tooth,  but  without  abscess  or  breach  of 
surface  in  the  vicinity  of  the  spot  where  it  was  lodged. 

From  the  facts  now  adduced,  it  seems  reasonable  to  establish 
the  following  conclusions. 

1.  Foreign  bodies,  such  as  kernels  and  stones  of  fruit,  nuts,  or 
fi’agments  of  them,  teeth,  natural  or  artificial,  pieces  of  metal,  wood, 
or  fragments  of  bones,  which  pass  the  glottis  and  drop  into  the 
windpipe,  if  they  do  not  produce  immediate  suffocation,  cause  irri- 
tation of  the  windpipe,  bronchi,  and  bronchial  membrane,  indicated 
by  fits  of  coughing,  more  or  less  continued  and  severe,  wheezing, 
breathlessness,  and  weight  and  oppression  in  the  chest. 

2.  These  symptoms  of  irritation  are  speedily  succeeded  by  symp- 
toms of  inflammation,  sometimes  acute,  sometimes  chronic,  but 
always  afterwards  becoming  chronic,  indicated  by  cough,  expecto- 
ration of  dense  puriform  or  purulent  mucus,  occasionally  streaked 
with  blood ; weight  and  anxiety  in  the  chest ; quick  pulse ; and 
eventually,  hectic  fever,  with  wasting, 

3.  Bodies  of  the  kind  now  specified  drop  not  constantly  but  most 
frequently  into  the  right  bronchus ; and  their  presence  is  followed 
by  inflammation  first  in  the  right  bronchial  tubes  and  lungs  of 
right  side.  The  right  bronchus  is  normally  more  directly  in  con- 
tinuation with  the  tracheal  canal  than  the  left  bronchus.  One  or 
two  instances,  nevertheless,  of  foreign  bodies  falling  into  the  left 
bronchus  have  occurred.* 

4.  These  bodies,  there  is  reason  to  believe  from  their  size  and 
shape,  must  be  arrested  in  the  large  or  middle-sized  bronchial 
tubes;  and  it  must  be  anatomically  and  physically  impossible  for 
them  to  descend  into  the  small  tubes  or  the  pulmonary  vesicles. 

5.  The  disease  induced  by  their  presence  must  therefore  be,  in 
the  first  instance,  tubular  bronchitis ; and  though  the  inflammation 
may  afterwards  extend  to  the  vesicular  membrane,  it  is  chiefly  the 
tubular  variety  of  the  disorder  throughout. 

6.  In  all  the  recorded  cases,  the  symptoms,  however  intense 

* Schroetier  Van  Der  Kolk. 


590 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


during  the  abode  of  the  body  in  the  bronchi^  and  though  enduring 
from  the  space  of  from  six  to  seven  weeks,  as  in  the  cases  of  Bor- 
sieri,  Dr  Donaldson,  and  Dr  J.  Scott,  to  that  of  several  months, 
as  in  the  case  by  Dr  Lettsom,  that  of  Dr  Nooth,  and  the  case  by 
Mr  Howship,  or  for  years,  as  in  those  by  Desault,  Louis,  Sue,  and 
Holman,  in  general  rapidly  subided  as  soon  as  the  foreign  body 
was  ejected. 

7.  In  two  cases  only,  that  by  M.  Sue,  and  the  one  which  occurred 
to  myself,  did  partial  and  temporary  recovery  take  place,  before  the 
ejection  of  the  foreign  body. 

8.  In  certain  cases  in  which  the  mechanical  configuration  of  the 
body  is  unfavourable  for  detachment  and  expulsion,  the  bronchitic 
symptoms  are  liable  to  be  extended  to  the  lung,  in  which  suppura- 
tion is  caused,  and  to  the  pleura,  in  which  effusion  of  lymph  and 
purulent  matter  is  induced. 

As  the  case  which  occurred  within  my  own  experience  has  not 
yet  been  published,  and  as  its  progress  and  termination  illustrate 
well  the  usual  characters  of  cases  of  this  class,  I subjoin  a short 
account  of  it. 

Master  L.  M.,  an  interesting  and  apparently  healthy  boy  of  about 
five  years  of  age,  had  suffered  occasionally  from  cough  during  winter. 

In  April  1843  he  had  measles,  and  made  a very  favourable  recovery. 
Soon  after  he  was  attacked  by  cough  of  extreme  violence. 

For  these  symptoms  remedies  were  judiciously  employed  by 
Dr  Watson  Wemyss.  The  cough  nevertheless  proceeded  and 
became  daily  more  urgent  and  distressing  ; expectoration,  at  first 
scanty,  was  attended  with  the  excretion  of  dense  puriform  mucus,  i 
occasionally  slightly  streaked  with  blood ; fever  was  added  and  be- 
came constant ; and  some  loss  of  flesh  as  well  as  of  strength  had 
taken  place. 

In  May  1843  I was  requested  to  see  the  boy.  I found  the  res- 
piration from  32  to  36  in  the  minute,  with  little  or  no  motion  cf 
the  upper  part  of  the  right  side  of  the  chest,  and  manifest  dulness 
on  percussion  all  over  the  subclavicular,  pectoral,  and  scapular  re- 
gions of  the  right  side.  Air  did  not  during  the  motions  of  inspira-  t 
tion  enter  the  right  side  of  the  lungs  freely ; and  seemed  to  be^W 
stopped  and  thrown  back  when  the  attempt  to  inspire  was  made.  i 
The  voice  was  a little  resonant  over  the  right  mammary  region ; 
and  the  beats  of  the  heart  were  heard  as  strongly,  clearly,  and  dis- 
tinctly as  if  the  heart  was  beating  under  the  ear.  Occasionally 


TRACHEO-BRONCHIAL  MUCOUS  MEMBRANE, 


591 


slight  wheezing  and  faint  mucous  rattles  were  heard  immediately 
below  the  right  collar  bone  and  through  the  right  scapula ; and 
when  the  patient  coughed,  the  expiration  sound  came  against  the 
ear  at  times  faintly,  at  other  times  with  unusual  force.  The  child 
complained  of  pain  in  the  right  mammary  region ; stretching 
sometimes  to  the  shoulder.  The  pulse  was  never  under  120  ; the 
child  perspired  much  during  the  night,  and  in  the  morning  violent 
and  alarming  fits  of  coughing  came  on  and  continued  long. 

On  the  left  side  of  the  chest  no  morbid  sounds  were  recognized. 
The  motions  of  the  chest  were  rapid  and  frequent ; but  air  seemed 
to  enter  and  quit  the  bronchial  tubes  of  the  left  side  without  much 
impediment,  excepting  what  arose  from  the  rapid  motion  of  that 
side,  and  of  the  diaphragm  and  abdominal  muscles. 

Leeches  were  applied  over  the  right  side  of  the  chest  several 
times,  according  to  the  strength  of  the  patient,  the  urgency  of  the 
symptoms,  and  the  eflrects  of  the  discharge.  Antimonial  medicines 
had  been  given ; and  ipecacuanha  wine,  with  occasional  doses  of 
tincture  of  hyoscyamus  were  tried.  The  bowels  were  kept  open 
by  means  of  calomel  and  rhubarb,  or  castor  oil ; and  afterwards 
small  doses  of  the  gray  powder,  {hydrargyrus  cum  creta)  were 
given.  Leeches  were  applied  often,  as  they  seemed  to  give  most 
relief ; and  once  or  twice  the  surface  of  the  right  side  of  the  chest 
was  blistered. 

At  length  after  treatment  of  this  kind  for  the  space  of  between 
five  and  six  weeks,  the  cough  became  less  urgent  and  frequent ; 
the  amount  of  expectorated  mucus  was  diminished ; the  pulse  be- 
came less  frequent ; the  night  sweats  diminished  and  better  sleep 
was  obtained ; and  appetite  returning,  the  child  took  food  with 
some  relish.  The  breathing  was  reduced  to  between  24  and  26  in  the 
minute ; but  there  was  still  much  dulness  over  the  whole  right 
mammary  region,  and  little  motion  of  that  side  of  the  chest  was 
observed,  while  the  beats  of  the  heart  were  heard  as  clearly  and 
distinctly  as  before. 

Sufficient  amendment  was  produced,  however,  and  sufficient 
strength  was  recovered  to  justify  the  cessation  of  medical  treatment, 
and  to  enable  the  patient  to  proceed  to  a country  situation  in  July 
1843.  Here  he  remained  for  six  weeks,  and  improved  much  in 
health  and  strength.  The  cough  had  left  him ; the  expectoration 
had  ceased ; and  he  had  recovered  his  wonted  looks.  In  this  state 
he  remained  the  early  part  of  the  winter  of  1843-4.  As  the  season 


592 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


advanced,  however,  the  cough  returned  in  a more  violent  form ; and 
in  the  spring  of  1844,  in  March,  symptoms  of  another  attack  of  ca-  i 
tarrh  appeared.  li 

At  first  the  usual  remedial  means  were  employed.  But  the  cough 
became  daily  more  urgent,  rending,  and  frequent;  the  muco-purulent 
expectoration  with  the  night  sweats  returned  ; the  pulse  was  never 
below  120;  the  flesh  was  wasting  fast;  and,  in  short,  the  patient 
was  again  rapidly  returning  to  his  state  in  May  1843. 

At  this  time  the  respiration  was  36  in  the  minute,  with  almost 
no  motion  of  the  right  side ; the  mammary  region  emitted  a dull 
sound,  and  was  visibly  flattened  and  depressed ; the  voice  was  re- 
sonant ; and  the  cardiac  beats  were  clearly  and  distinctly  heard  all 
over  the  mammary  region  before,  and  the  scapular  region  behind. 
Little  respiration  was  audible,  and  only  now  and  then  a slight  rattle. 
About  one  inch  below  the  right  collar-bone,  extending  downwards 
about  three  inches ; and  from  one  inch  from  the  sternum  to  the 
outer  margin  of  the  large  pectoral  muscle  before,  little  or  no  natu- 
ral respiration  was  heard.  The  same  phenomena  were  recognized 
behind.  When  inspiration  was  observed,  it  appeared  that  the  air 
never  penetrated  further  down  than  half  an  inch,  or  three-fourths  | 

of  one  inch  below  the  right  collar-bone,  and  about  the  same  corre-  i 

spending  point  behind.  Respiration  was  performed  mostly  by  the  j 
diaphragm. 

On  the  other  hand,  over  the  whole  of  the  left  side  respiration  was 
clear  and  good ; and  though  there  v/ere  rattles  in  several  points, 
they  indicated  nothing  very  bad. 

I was  satisfied  at  this  time,  March  1844,  that  there  had  been  pleu- 
risy with  considerable  effusion  ; pneumonia  with  consolidation ; and 
bronchitis,  but  of  what  nature  it  was  not  easy  to  say.  From  the 
recurrence  of  the  symptoms,  it  seemed  probable  that  the  lungs  were 
tuberculated ; and  although  there  was  no  distinct  evidence  of  any 
vomica,  or  excavated  part,  the  sounds  heard  led  me  to  think  that 
almost  no  respiration  was  performed  by  the  upper  and  middle  lobes 
of  the  right  lung. 

Treatment  was  resumed,  very  much  of  the  same  kind  as  before,  i 
regulating  the  diet  as  carefully  as  possible.  The  symptoms  proceed-  ■ 
ed,  being  sometimes  more  intense,  sometimes  alleviated,  but  never 
disappearing.  At  length,  after  a long,  violent,  and  distressing  fit 
of  coughing  on  the  morning  of  the  10th  March  1844,  the  patient 
coughed  up  an  iron  screw  nail,  about  three-fifths  or  three-fourths 
of  one  inch  long,  with  a head  with  very  sharp  edges,  covered  with 


TRACHEO-BRONCHIAL  MUCOUS  MEMBRANE. 


593 


purulent  matter  and  a little  blood,  and  completely  rusted.  This 
was  presented  to  me  at  my  visit ; and  though  the  symptoms  were 
still  urgent  and  by  no  means  diminished,  I inferred  now  that  there 
was  every  prospect  that  the  patient  would  get  rid  of  his  disease. 

In  this  expectation  I was  not  disappointed.  At  first  after  the 
ejection  of  the  screw-nail,  the  cough  seemed  to  be  aggravated  ; and 
expectoration  did  not  immediately  diminish  in  quantity.  The  pa- 
tient also  suAFered  from  abdominal  pains,  which  depended  on  a small 
umhilical  hernia,  which  was  protruded  during  the  fits  of  coughing. 
Eventually,  however,  the  cough  abated ; the  expectoration  gradually 
diminished,  and  at  length  ceased ; the  respiration  fell  to  26,  24, 
20  ; the  pulse  came  down  to  80  ; the  appetite,  which  had  not  been 
in  this  attack  bad,  was  active ; and  flesh  and  strength  returned  in 
the  course  of  about  four  or  five  weeks. 

The  surface  of  the  mammary  region  was  still  dull ; and  little 
respiration  was  heard  ; but  the  chest  was  moving  a little  ; and  the 
patient  appeared  to  suffer  no  inconvenience. 

In  July  he  again  went  to  a country  situation,  and  residing  there 
for  several  weeks,  returned  home  strong  and  free  from  any  apparent 
complaint. 

When  the  screw  nail  was  coughed  up  by  this  child,  it  became  a 
point  of  importance  to  ascertain  when  and  how  it  had  been  intro- 
duced into  the  larynx  and  trachea.  On  these  points,  however,  all 
enquiry  was  unavailing.  One  thing  only  was  certain,  that  the  nail 
must  have  been  in  the  right  bronchus  since  April  1843,  probably  at 
a date  previous  to  that  time.  It  must,  therefore,  have  continued 
there  at  least  13  months,  probably  nearer  14  or  15  months. 

This  boy  has  since  that  time  remained  in  good  health,  and  free 
from  any  bronchial  or  pectoral  ailment.  The  mammary  region  is 
still  flatter  and  more  depressed  on  the  right  side  than  on  the  left, 
and  emits  a sound  a little  dull ; but  respiration  is  performed  faintly  ; 
and  it  is  clear  that  the  lower  part  of  the  right  lung  is  tolerably 
good. 

In  this  case  I think,  that  it  is  quite  impossible  to  doubt,  that  the 
screw  nail  had  been  lodged  in  the  right  bronchus ; that  its  presence 
there  had  caused  first,  inflammation  of  the  whole  of  the  upper 
bronchial  tubes ; then  inflammation  of  the  substance  of  the  lung  in 
a certain  degree ; and  at  the  same  time  pleuritic  inflammation.  I 
have  no  doubt  that  the  whole  upper  and  middle  lobes  are  adher- 
ing by  their  pleura  to  the  pleura  costalis. 


pp 


594 


GENERAL  AND  PATHOLOGICAL  ANATOTIY. 


Of  this  case  it  is  a circumstance  not  the  least  remarkable,  that 
decided  abatement  in  the  symptoms  took  place  in  June  1843,  and 
temporary  recovery  continued  during  autumn  and  winter,  while  the 
nail  was  still  fixed  in  the  bronchial  tubes. 

§ 4.  Emphysemaof  the  lungs  as  a result  of  bronchitis. — Though  this 
probably  should  be  placed  under  the  head  of  diseases  of  the  sub- 
stance of  the  lungs,  yet  it  may  maintain  the  anatomical  connection 
more  closely  by  considering  it  here. 

In  the  early  stage,  indeed,  of  bronchitis.^  there  is  simply  a diffuse 
or  spreading  inflammation  or  congestion  of  the  pulmonary  mucous 
membrane ; and  after  it  has  subsided  under  proper  treatment,  that 
membrane,  both  where  it  lines  the  bronchial  tubes  and  pulmonary 
vesicles,  sooner  or  later  returns  to  its  natural  condition ; while  the 
calibre  of  these  tubes,  and  the  capacity  of  the  vesicles,  is  little  or 
not  at  all  lessened.  Either,  however,  after  repeated  attacks  or  long 
continuance  of  this  disease,  not  only  does  the  inflammatory  process 
extend  from  the  mucous  membrane  to  the  submucous  or  pulmonary 
filamentous  tissue,  but  by  its  long  endurance  it  renders  the  former 
thick,  villous,  and  brownish-coloured,  secreting  either  much  viscid 
mucus,  or  mucus  more  or  less  tinged  with  blood,  and  even  occasion- 
ally pure  blood,  and  indurates  and  solidifies  the  latter  by  the  extra- 
vasation of  albuminous  fluid  ; while  the  increased  thickness  of  the 
membrane,  and  the  swelling  of  the  submucous  tissue,  encroach  so 
much  upon  the  area  of  the  bronchial  tubes  and  vesicles,  as  to  dimi- 
nish remarkably  the  capacity  of  these  cavities. 

This  swelling,  however,  of  the  pulmonary  mucous  membrane  and 
filamentous  tissue,  is  not  general  over  the  whole  of  the  tubes,  nor 
even  over  the  whole  of  one  tube,  otherwise  it  would  produce  fatal 
asphyxia.  But  it  in  general  takes  place  at  certain  spots  in  the 
course  of  the  tubes  more  remarkably  than  at  others,  producing  a 
species  of  stricture  of  one  or  more  bronchial  tubes  in  one  or  both 
lungs.  The  effect  of  this  again  is  various,  according  to  its  degree, 
and  according  to  the  component  systems  and  textures  of  the  lung 
most  aflfected.  One  of  the  most  frequent  eflfects  of  the  presence  of 
one  of  these  constricted  portions,  especially  if  the  membrane  secretes 
much  viscid  mucus,  which  requires  to  be  frequently  coughed  up,  is 
to  obstruct  the  passage  so  much  that  expiration  becomes  either  in- 
adequate or  is  interrupted.  As  respiration  consists,  therefore,  in 
alternate  inspiration  and  expiration,  if  air  has  been  either  inhaled 
by  this  tube,  or  by  some  of  the  communicating  ones,  it  cannot,  dur- 


TRACIIEO- BRONCHIAL  MUCOUS  MEMBRANE. 


595 


ing  ordinary  expiration,  be  easily  expelled.  The  effect  is,  that  the 
bronchial  membrane  and  pulmonary  vesicles  are  excited  by  their 
physiological  properties  to  frequently  repeated  expiratory  efforts ; 
and,  as  these  are  inadequate  to  expel  the  air  from  the  lungs,  the 
compression  of  the  expiratory  muscles  necessarily,  by  forcing  the 
portion  of  lung  into  smaller  compass,  compresses  the  air  already 
contained  in  the  vesicles  beyond  the  constricted  point.  The  air 
thus  confined,  after  many  repeated  expiratory  efforts,  forces  its  way, 
by  its  own  elasticity,  through  the  delicate  mucous  membrane  of 
the  vesicles  into  the  pulmonic  filamentous  tissue,  and,  when  once 
there,  it  continues  to  spread  rapidly  in  proportion  to  the  obstruc- 
tion in  the  bronchial  tubes,  and  the  difficulty  of  producing  efficient 
expiration.  It  is  then  that  the  air  contained  in  these  vesicles  ren- 
ders the  chest,  when  struck,  preternaturally  resonant ; while  the 
extreme  difficulty  of  breathing,  with  the  dry  sonorous  rhonchus  or 
sibilism,  indicate  the  laborious  struggle  which  is  made  in  the  tubes, 
contracted  by  swelling,  and  obstructed,  as  they  are,  by  adherent 
mucus, — to  inspire  and  to  expire  in  an  efficient  manner. 

In  this  manner,  therefore,  bronchial  inflammation,  either  by  con- 
tinuance or  repeated  attacks,  tends  to  produce  emphysema  and  its 
usual  phenomena ; and  there  are  few  cases  of  emphysematous  dis- 
tension of  the  pulmonic  filamentous  tissue  which  may  not  be  traced 
to  this  cause.  In  the  young,  when  labouring  under  hooping-cougb, 
in  the  aged,  after  frequently  repeated  attacks  of  catarrh,  and  in  the 
middle-aged  after  the  continuance  of  bronchial  inflammation,  in  a 
subacute  or  chronic  state,  emphysema  is  with  equal  certainty,  and 
in  equal  perfection,  produced.  In  the  first  case,  indeed,  as  the 
bronchial  symptoms  subside,  the  tubes  become  more  pervious,  and 
expiration  becomes  so  much  freer  and  less  interrupted,  that  the 
air  ceases  to  be  urged  through  the  vesicular  membrane,  and  that 
which  had  been  already  impelled  into  the  pulmonic  filamentous  tissue 
is  at  length  absoi’bed.  But  in  the  two  latter  instances,  in  which  the 
thickening  of  the  membrane  either  abates  little,  or  continues  un- 
changed, the  emphysematous  distension  continues  to  increase,  until 
it  has  attained  an  extent  almost  incredible  to  those  unaccustomed  to 
examine  cases  of  chronic  bronchial  disease. 

Emphysema,  however,  is  not  the  only  eflfect  of  this  state  of  the 
bronchial  tubes.  The  impracticability  of  inspiring  and  expiring 
completely  in  such  a state  of  the  lungs,  which  implies  the  absence 
of  the  most  essential  condition  of  respiration,  vfr.  the  frequent  and 


596 


GENERAL  AND  rATIlOLfXaCAL  ANATOMY. 


incessant  change  of  air  in  the  hronchial  tnhes  and  vesicles  of  the 
lungs,  interferes  with  the  necessary  changes  in  the  blood  of  the 
pulmonary  artery  and  veins,  which,  therefore,  passes  from  the  former 
vessel  into  the  latter,  much  less  completely  aerated  than  it  would 
be  in  the  healthy  state.  In  addition  to  this,  as  the  motion  of  the 
blood  through  the  pulmonary  artery  into  the  pulmonary  veins  is 
always  more  free,  in  proportion  as  the  expansion  of  the  lung  by  in- 
spiration, and  its  collapse  by  expiration,  is  extensive  ; and  as  both 
the  obstruetion  of  the  bronchial  tubes  by  viscid  mucus,  and  the 
swelled  and  congested  state  of  the  hronchial  membrane  and  sub- 
mucous tissue,  prevent  the  branches  of  the  artery  and  veins  from 
freely  expanding  themselves  ; the  motion  of  the  blood  through  this 
order  of  vessels  begins  to  be  interrupted  and  retarded,  and  thus  to 
induce  a congested  state  of  the  whole  pulmonary  system,  which  not 
only  adds  to  the  dyspima  and  orthopnoea  of  such  patients,  but  even- 
tually terminates  in  dropsical  effusion  into  the  pulmonic  filamentous 
tissue,  within  the  cavity  of  the  pleura,  and  even  into  the  general  cel- 
lular membrane.  The  pulmonic  filamentous  tissue  is  in  general 
the  first  seat  of  this  dropsical  infiltration ; and  it  is  one  of  the  most 
common  changes  recognized  in  inspecting  the  lungs  of  persons  cut 
off  by  long-continued  bronchial  inflammation. 

Chronic  bronchial  inflammation,  further,  by  its  influence  in  im- 
peding respiration  and  the  circulation  of  the  pulmonary  artery  and 
veins,  has  an  indirect  tendency  to  induce  disease  of  the  heart.  In 
consequence  of  the  difficulty  which  the  blood  encounters  in  passing 
through  the  branches  of  the  pulmonary  artery,  the  trunk  of  that 
vessel  becomes  permanently  distended  ; and  the  right  ventricle, 
being  also  distended  and  incessantly  excited  to  new  contractions, 
becomes  affected  with  hyperti’ophy,  sometimes  with  dilatation,  some- 
times without ; and  in  other  cases  it  may  be  merely  enlarged  with 
extenuation  of  its  walls.  It  is,  I conceive,  in  consequence  of  the 
union  of  the  two  ventricles  in  the  human  subject,  that  this  exces- 
sive distension  and  inordinate  action,  by  being  first  confined  to  the 
right  ventricle,  gives  I’ise  to  a similar  inordinate  action  in  the  left 
ventricle,  that  the  latter  is  often  found  in  a state  of  hypertrophy  in 
persons  who  have  long  laboured  under  chronic  bronchial  disease. 
The  fact  of  the  connection  is  at  least  well-established ; and  hos- 
pital practice  presents  few  instances  of  bronchial  disease  in  wffiich 
the  heart  is  not  affected ; and  in  most  of  the  cases  of  disease  of  the 
heart,  the  bronchial  membrane  and  pulmonic  tissue  are  previously 
affected. 


TRACIIEO-BROXCIIIAL  MUCOUS  MEMBRANE. 


597 


§ 5.  Bronchitis  from  inhalation  of  particles  of  sand,  dust,  and  metal, 
— Next  to  bronchial  disease  from  the  presence  of  foreign  bodies,  may 
be  placed  that  form  of  the  disease  which  is  the  result  of  the  inhala- 
tion of  sand,  dust,  or  metallic  particles  in  minute  mechanical  divi- 
sion. This  has  been  already  mentioned  in  a general  manner.  But 
it  may  be  proper  to  advert  more  particularly  to  the  changes  induc- 
ed in  the  lungs  as  presented  by  the  artisans  of  Sheffield. 

These  changes  are  not,  indeed,  by  any  means  confined  to  the 
bronchi  or  their  branches  and  membrane.  But  as  the  primary  cause 
is  applied  first  to  the  membrane  of  these  tubes,  it  seems  reason- 
able to  consider  the  different  lesions  thus  arising  in  the  present 
place. 

In  the  town  and  vicinity  of  Sheffield  two  sorts  of  grinding  of 
edged  tools  are  practised ; one  dry  grinding,  on  a dry  stone,  the 
other  wet  grinding,  on  a stone  moistened  with  water.  Many  ai’- 
ticles,  as  scissors,  razors,  and  penknives,  are  ground  partly  on 
dry  stone,  and  partly  on  the  wet  stone.  Others,  as  forks  and 
needles,  are  ground  mostly  on  a dry  stone.  Table  knives  are 
ground  principally  on  a wet  stone.  Saws,  files,  and  scythes  are 
ground  entirely  on  a wet  stone. 

Dry  grinding  is  most  injurious,  and  tends  most  directly  and  ef- 
fectually to  induce  bronchial  and  pulmonary  disease,  and  thereby 
to  abridge  the  duration  of  life  among  the  grindei's.  The  dry 
grinders,  therefore,  are  most  speedily  destroyed.  The  life  of  the 
wet  grinder  is  often  prolonged  to  a considerable  age. 

Of  1000  scissor-grinders  above  20  years  of  age,  only  20  attain 
the  age  of  between  51  and  55  years,  only  10  the  age  of  between  61 
and  65,  and  none  live  beyond  the  latter  age  ; while  of  the  inhabi- 
tants of  Sheffield  generally,  244  in  1000  are  found  living  at  65  and 
above,  and  in  tbe  midland  counties,  413  in  1000.  Of  artisans  in 
this  branch  843  in  1000  die  under  45  years  of  age. 

With  the  fork-grinders  it  is  worse.  Among  1000  fork-grinders, 
aged  above  20  years,  not  one  attains  the  age  of  59  ; while  in  Shef- 
field, among  1000  persons  155  are  living  at  59.  Of  these  1000 
persons  472  die  between  20  and  29  years,  410  between  30  and  39  ; 
and  the  residual  115  are  all  gone  before  the  age  of  50. 

Among  1000  razor-grinders  above  20  years  of  age,  749  die  un- 
der 41  years  of  age  ; the  rest  mostly  between  41  and  60;  between 
61  and  65  only  5 are  living;  and  after  65  all  are  gone. 

Of  the  pen-knife  grinders  not  one  in  1000  arrives  at  the  age  of 


598 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


60  ; 731  die  before  the  40th  year;  and  the  rest  are  all  destroyed 
before  the  60th  year. 

Saw-grinders,  file-grinders,  and  scythe-grinders,  who  work  on  the 
wet  stone,  are  less  liable  to  bronchial  disease  and  are  longer  lived. 
The  numbers  pursuing  saw-grinding  are  not  great.  Tet  among  78 
persons  engaged  in  it  in  1843,  9 were  between  60  and  65,  and  one 
died  betv/een  66  and  70,  and  one  at  79.  The  number  of  scythe- 
grinders  is  also  not  great.  In  1843  there  were  30;  and  of  these 
8 were  between  41  and  60  years  of  age.  Both  the  saw-grinders  and 
the  scythe-grinders  are  exposed  to  accidents,  sometimes  fatal,  from 
the  breaking  of  the  stone. 

The  lesions  which  produce  this  great  mortality  are  of  a compli- 
cated character.  The  most  common  lesions  are  chronic  inflamma- 
tion with  thickening  of  the  bronchial  membrane,  enlargement  or 
dilatation  of  the  bronchial  tubes,  emphysema,  and  expansion  of  the 
pulmonic  tissue.* 

The  bronchial  glands  are  enlarged,  or  converted  into  a hlack 
hard  gritty  substance,  varying  in  size  from  half  a marble  to  a large 
hazel  nut.  In  dividing  these  glands,  the  sound  emitted  is  the  same 
as  if  the  scalpel  were  dividing  a soft  stone  ; and  the  section  is  black 
and  polished,  and  grates  over  the  edge  of  the  knife.  Such  masses 
are  commonly  detected  in  grinders  who  have  belonged  to  the  most 
destructive  branches.f 

Similar  soft  sectile  gritty  or  stony  matter  is  found  in  almost 
every  part  of  the  lungs,  in  portions  varying  from  the  size  of  a cur- 
rant to  that  of  a bean. 

Adhesions  between  the  pulmonic  and  costal  pleurcB  are  also  fre- 
quent. 

In  some  instances  the  lungs  present  an  appearance  as  if  black 
currants  had  been  distributed  through  their  whole  substance,  and 
accompanied  with  similar  bodies  larger  in  size,  but  hard  and  gritty 
like  them.  These  currant-like  bodies  are  also  observed  on  the  sur- 
face of  the  lungs.  As  to  their  nature  Dr  Holland  gives  no  opinion. 
But  Dr  C.  Fox  Favell  states  that  frequent  examination  has  con- 
vinced him  that  they  consist  of  the  dilated  extremities  of  veins  con- 
taining some  of  the  solid  constituents  of  the  blood. 

* Diseases  of  the  Lungs  from  Mechanical  Causes.  By  G.  Calvert  Holland,  M.  D., 
p.  12.  London,  1843,  8vo. 

-)-  Ibid.  p.  41 . 


TRACHEO-BRONCHIAL  MUCOUS  MEMBRANE. 


599 


Tubercles  are  also  occasionally  found  with  their  consequences, 
vomicae. 

Another  state  frequently  observed  is  engorgement  or  infil- 
tration of  the  lungs  with  a dark-colourcd  fluid,  which  is  ascribed 
by  Dr  Holland  to  the  inhalation  of  the  fine  black  dust  floating  in 
the  atmosphere  during  the  operation  of  glazing. 

On  the  mode  of  production  of  these  lesions,  or  the  order  of  their 
succession,  observers  are  not  agreed.  Dr  Arnold  Knight  and  Dr 
Holland  consider  the  tracheo-bronchial  membrane  to  be  the  original 
and  principal  seat  of  the  disease,  and  the  tracheo-bronchial  irritation 
to  be  the  primary  morbid  action,  and  to  give  rise  to  all  the  other  ef- 
fects ; the  dilatation  of  the  bronchi,  emphysema,  the  formation  of  cur- 
rant-like bodies,  tubercles,  pulmonary  induration,  and  pleuritic  ad- 
hesion. Dr  Fox  Favell,  on  the  other  hand,  thinks  that  the  pulmonic 
tissue  or  parenchyma  is  the  primary  and  essential  seat  of  the  dis- 
ease, does  not  regard  the  mucous  membrane  as  the  original  seat  of 
the  disease,  and  maintains  that  the  organic  changes  found  in  the 
structure  of  the  lungs  constitute  the  essence  of  the  lesion  ; in  short, 
that  all  the  changes  seen  in  the  lungs  of  the  grinders  depend  on 
congestion  and  inflammation  of  their  parenchymatous  structure.* 
Dr  Favell,  in  short,  ascribes  as  much  to  the  position,  the  labour, 
and  the  debauched  habits  of  the  grinders,  as  to  the  inhalation  of  the 
dust  or  powder.  The  question  is  not  easily  determined.  But  it 
may  safely  be  asked,  how  the  wet  grinding  is  so  little  hurtful,  and 
the  dry  grinding  so  rapidly,  powerfully,  and  effectually  detrimental 
to  the  lungs.  It  is  also  to  be  observed,  that  it  cannot  be  said  to 
follow,  because  the  pulmonic  parenchyma  is  found  much  diseased, 
that  the  tracheo-bronchial  membrane  is  not  the  primary  seat  of 
mischief.  It  is  known  that  various  affections  of  the  tracheo-bron- 
chial membrane  do  extend  to  the  lungs ; and  there  is  little  reason 
to  believe  that  the  grinder’s  asthma  constitutes  an  exception  to  the 
rule, 

§ 6.  Bronchial  inflammation  takes  place  secondarily  in  hooping- 
cough,  measles,  scarlet  fever,  small-pox,  and  typhous  fever.  In 
measles  I have  seen  the  membrane  red,  injected,  villous,  and  secret- 
ing puriform  fluid  copiously — tbe  usual  symptoms  of  pulmonary 
consumption  having  preceded  the  fatal  event.  In  scarlet  fever  not 
only  the  pulmonic  but  the  facial  mucous  membrane  is  inflamed ; and 

^ Oil  Grinder’s  Asthma,  By  Charles  Fox  Favell,  M,  D.  Ac.  Transactions  of  the 
Provincial  Medical  and  Surgical  Association.  New  Series.  Vol.  ii.  1846,  p.  143. 

4 


600 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


in  some  severe  and  fatal  cases  I have  traced  the  capillary  injection 
along  the  gastro-enteric  division,  and  in  the  genito-urinary  from 
the  neck  of  the  bladder  to  the  pelvis  of  the  kidney.  ' This  general 
affection  of  the  raucous  system  explains  the  fatality  as  well  as  many 
of  the  symptoms  of  scarlet  fever.  Inflammation  of  the  tracheo- 
bronchial membrane  is  an  occasional  consequence  of  inhaling  acci- 
dentally certain  of  the  noxious  gases. 

Redness  and  punctular  injection  of  the  tracheo-bronchial  mem- 
brane, with  more  or  less  secretion  of  viscid  mucus,  was  seen  in 
hydrophobic  subjects  by  Beddoes,  Babington,  Oldknow,  Rush,  Sat- 
terley,  Brandreth,  and  Trolliet,  the  last  of  whom  labours  to  prove 
that  the  rabid  poison  affects  particularly  this  membrane.  Much  of 
this  effect  is  doubtless  to  be  ascribed  to  the  violence  of  the  abnormal 
motions  of  the  respiratory  muscles ; and  it  is  still  undetermined 
how  far  the  appearances  now  mentioned  are  primary  and  essential, 
or  secondary  and  accessary. 

§ 7.  Obliteration  and  Arctation  of  the  Bronchial  Tubes. — From  the 
operation  of  various  causes  at  present  not  well  understood,  the  bron- 
chial tubes  are  liable  to  be  narrowed  or  contracted,  and  in  certain 
instances  their  canal  may  be  entirely  closed  and  obliterated.  Arc- 
tation or  narrowing  of  the  bronchial  tubes  has  been  already  men- 
tioned as  one  of  the  effects  of  bronchial  inflammation,  recurring  re- 
peatedly, and  becoming  at  length  chronic.  In  cases  of  this  kind, 
these  walls  forming  the  tube  are  distinctly  thickened  by  effusion 
either  of  blood  or  lymph,  or  both,  into  the  submucous  tissue ; and 
the  capacity  of  the  tube  is  proportionally  diminished.  . In  other  in- 
stances the  presence  of  indurated  or  hemorrhagic  portions  of  lung 
round  small  bronchial  tubes  produce  the  same  diminution  in  their 
normal  dimensions  i 

Of  obliteration,  M.  Reynaud,  who  has  studied  this  lesion,  has 
observed  four  forms.  ^ 

In  the  first  kind  complete  coalescence  of  the  walls  of  a bron- 
chial tube  takes  place  without  foreign  matter  contained  in  their  in- 
terior, and  without  any  cause  of  external  compression. 

The  simplest  and  most  elementary  degree  of  this  obliteration  of 
the  bronchi  consists  in  closure  or  obliteration  of  the  terminal  end 
of  one  tube  or  more. 

This  sort  of  obliteration,  to  which  may  be  referred  several  lesions 
of  the  lungs,  takes  place  both  generally  over  a space  of  lung  more- 
or  less  extensive,  and  locally  in  one  or  more  bronchial  tubes.  In 


■'A 


TRACHEO-BRONCHIAL  MUCOUS  MEMBR.yS"E. 


601 


the  former  case,  the  substance  of  the  organ,  instead  of  being  vesi- 
cular or  spongy,  becomes  solid,  compact,  and  impermeable  to  the 
air. 

A second  sort  of  bronchial  obliteration,  differing  from  the  pre- 
ceding one  in  its  seat,  is  what  is  observed  in  bronchial  canals  of  the 
fifth  or  sixth  order,  consequently  very  near  their  termination,  and 
some  lines  from  the  pleura,  yet  in  the  interior  of  the  parenchyma  of 
the  lungs.  In  this  variety  the  obliteration  takes  place  at  a part  of 
the  bronchial  tube,  where  the  area  is  still  considerable  enough  to 
furnish  divisions.  But  M'hei’e  the  lung  is  divided,  the  tube  is  ob- 
served suddenly  to  terminate  in  a blind  sac  ; and  beyond  the  point 
of  obliteration,  the  bronchial  tube  is  seen  distinctly  continuous,  with 
a small  firm,  resisting  cord,  itself  furnishing  small  ramifications,  and 
easily  detached  by  slight  scraping  from  the  rest  of  the  lung.  The 
bronchial  tube  may  thus  be  traced  to  the  ■pleura. 

A third  sort  is  that  in  which  the  obliteration  is  seated,  as  in  the 
second,  at  a distance  nearly  equal  from  the  pleura.  The  chief  dif- 
ference is  this,  that  while  the  second  form  can  be  recognized  only  by 
cautiously  and  gradually  dividing  the  small  bronchial  tubes  by  means 
of  delicate  scissors,  the  present  form  is  easily  discovered  by  a common 
blunt  probe,  which,  when  introduced  into  the  principal  bronchus,  is 
suddenly  stopped,  while,  if  carried  into  the  neighbouring  ramifica- 
tions placed  at  the  same  distance,  it  penetrates  more  forward.  When 
the  bronchus  thus  obstructed  is  laid  open  down  to  the  site  of  obstruc- 
tion, it  is  observed  that  the  obstruction  is  owing  to  an  obliteration 
seated  in  a large  tube,  which,  though  near  the  surface  of  the  lung, 
does  not  appear  with  the  characters  peculiar  to  dilatation  of  the 
bronchi.  The  obliterated  bronchus  is  continuous  with  a fibrous 
cord  ; but  this  is  larger  than  in  the  preceding  case,  though  its  course 
to  the  pleura  is  not  longer. 

To  the  disposition  now  mentioned  is  conjoined  another  referable 
to  the  surface  of  the  lung,  and  which  denotes  the  presence  of  the 
obliteration.  This  consists  in  more  or  less  shrivelling  of  the  pul- 
monic surface  at  the  point  corresponding  to  the  seat  of  the  oblite- 
ration. From  this  it  is  reasonable  to  infer  that  the  shrivelling  is 
in  some  manner  connected  with  the  bronchial  obliteration.  It  is 
indeed  not  difficult  to  understand  how  the  obliteration  of  a bronchus, 
not  remote  from  the  surface  of  the  lung,  involving  that  of  the 
branches  issuing  from  it,  must,  by  the  consequent  contraction,  pro- 
duce contraction  or  shrinking  of  the  pulmonic  substance,  and 


602 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


shrivelling  more  or  less  considerable  of  the  surface  of  the  organ 
at  the  corresponding  point.  j 

These  shrivelled  spots  are  easily  recognized.  The  pleura  is  ! 
drawn  to  one  or  two  points  in  a series  of  wrinkles,  imperfectly  ra- 
diated ; the  surface  is  perceptibly  depressed  ; and,  when  the  part  is 
touched,  it  is  found  to  he  solid,  adherent,  firm,  and  inelastic.  i 

The  fourth  and  last  sort  of  obliteration  is  that  which  is  observed  i 
in  bronchial  tubes  larger  than  those  affected  in  the  previous  cases, 
and  furnishing  tubes  to  portions  of  the  lung  more  or  less  consider- 
able. This  sort  of  obliteration  diJffers  from  the  third  in  no  respect 
unless  in  the  greater  number  of  bronchial  tubes  the  obliteration  of 
which  it  involves.  It  also  produces  peculiar  forms  of  morbid  struc-^,j 
ture. 

This  obliteration  is  observed  in  the  bronchi  at  all  points  of  the;  ,T 
bronchial  tree,  from  the  branches  issuing  from  the  first  bronchus,  to^:  s 
those  which  may  be  divided  by  ordinary  scissors.  The  obliteratioii^  ,| 
is  known  as  in  the  third  case,  by  the  abrupt  termination  of  a large  : | 
tube  in  a blind  sac,  and  with  ligamentous  cords  proceeding  froni\  J 
it  through  the  lung. 

The  most  common  seat  of  these  obliterations  is  the  upper  lobe'  ' 
of  the  lung  and  especially  its  apex,  a fact  of  which  it  is  necessary’  i 
to  be  aware,  in  distinguishing  these  obliterated  spots  from  alleged  ^ 
healed  tubercular  cavities.  They  have  been  found  nevertheless  in 
the  lower  lobe.  Reynaud  found  the  lesion  twice  in  this  situation. if?™ 
As  to  the  state  of  the  bronchi  and  their  membrane  in  this  lesion,  l1 

I 

it  is  variable.  Sometimes,  I believe  very  rarely,  it  is  found  in  what  / 
is  called  perfect  integrity,  in  that  portion  accessible  to  air.  This 
is  certainly  sometimes  the  case.  On  the  other  hand,  the  membrane 
may  be  and  often  is  red,  rough,  thickened,  and  covered  with  viscid 
opaque  mucus.  Occasionally  the  tube  is  much  dilated  immediately 
above  the  point  of  obliteration  ; and  though  this  dilatation  may  take 
place  in  bronchi  of  all  sizes  and  in  all  points,  yet  it  is  most  common 
in  those  in  which  obliteration  affects  large  trunks,  at  a short  dis- 
tance from  their  origin. 

In  some  instances  the  adjoining  bronchi  to  one  which  has  been 
obliterated,  are  all  more  or  less  dilated,  and  instead  of  forming  cones 
gradually  contracting,  as  in  the  healthy  state,  are  either  cylinders, 
or  present  actual  dilated  and  enlarged  portions.  In  these  tubes 
the  membrane  is  generally  reddish,  rough,  and  covered  with  opaque 
purlform  mucus. 


TRACHEO-BEONCHUL  MUCOUS  MEMBRANE. 


603 


The  pulmonary  parenchyma  round  an  obliterated  bronchus  may 
present  two  morbid  states.  It  may  be  either  consolidated,  dense, 
and  firm,  as  already  mentioned,  or  it  may  be  emphysematous,  that 
is,  containing  air  in  the  pulmonic  cellular  tissue,  or  in  the  shape  of 
bladders  beneath  the  pleura.  In  some  instances  both  states  are 
associated.  Immediately  round  the  seat  of  the  obliteration  the  lung 
is  firm  and  dense,  with  shrivelling  of  the  pleura  and  pulmonic  sur- 
face ; and  beyond  this  dense  spot  again  the  surface  of  the  lungs  is 
pale,  white,  crepitating,  and  emphysematous;  and  two  or  more  air- 
bladders  are  formed  beneath  the  pleura.  Lastly,  it  is  not  unusual 
to  find  the  upper  lobe  presenting  shrivelled  patches,  and  the  indi- 
cations of  obliterated  bronchial  tubes;  and  the  middle  and  lower 
lobes  to  be  pale,  white,  crepitating,  and  more  or  less  extensively 
emphysematous. 

The  blood-vessels  are  not  obliterated ; except  in  the  minute 
branches  distributed  through  the  indurated  portion. 

The  solid  filaments,  the  relics  of  the  obliterated  tubes,  are  gene- 
rally of  a deep  black  colour. 

The  causes  of  obliteration  of  the  bronchial  tubes  are  not  posi- 
tively ascertained.  All  that  is  known  is  this;  that  obliteration 
takes  place  in  persons  who  had  laboured  under  severe,  repeated,  or 
long-continued  attacks  of  bronchial  inflammation,  usually  chronic, 
and  those  who  had  attacks  of  chronic  pneumonia.  Reynaud  is  in- 
clined to  ascribe  the  occurrence  of  the  lesion  to  diphtheral  or  albu- 
mino-facient  inflammation  of  the  bronchi;  and  there  is  no  doubt 
that  the  bronchial  membrane  is  liable  to  this  form  of  inflammation, 
and  that  this  form  of  inflammation  may  produce  or  terminate  in 
obliteration.  He  admits  also  that  he  has  met  with  cases  of  acute 
pneumonia  with  hepatization  of  the  lung,  in  which  the  lesion  con- 
sisted in  inflammation,  which  had  in  all  the  small  bronchi  given  rise 
to  the  formation  of  false  membranes,  which  filled  more  or  less  ac- 
curately all  their  cavities.* 

r rom  what  I have  myself  seen,  I ascribe  the  lesion  either,  as  al- 
ready stated,  to  severe  and  repeated  attacks  of  chronic  bronchitis^ 
or  to  the  effects  of  chronic  pneumonia. 

A lady  presented  the  usual  symptoms  of  very  severe  chronic 
bronchitis ; that  is,  cough,  expectoration  of  muco-purulent  matter, 
with  hectic  fever,  and  pulse  varying  from  110  to  120.  There  was 

^ Memoire  sui-  I’Obliteration  des  Bronches.  Par  A.  C.  Reynaud,  D.  M.,  &.c.  Me 
moires  de  I’Academie  Royale  de  Medecine,  Tome  ivieme.  Paris,  1835.  4to.  P.117. 


604 


GENERAL  AND  rATIlOLOGICAL  ANATOMY. 


strong  resonance  of  the  voice  at  the  upper  part  of  the  right  side  of 
the  chest;  and  the  cardiac  and  arterial  beats  were  heard  most  audibly. 
Yet,  though  the  symptoms  continued  long,  there  was  no  distinct 
indicalion  of  pectoriloquy.  The  subclavian  and  pectoral  regions 
also  before,  and  the  scapular  behind,  emitted  a dull  sound.  These 
symptoms,  which  were  attended  with  wasting  and  much  loss  of 
strength,  after  lasting  for  many  weeks,  at  length  subsided;  and 
she  seemed  to  recover  completely.  The  dull  sound  on  percussion 
continued,  however ; and  little  respiratory  murmur  was  audible  in 
the  uppei’  region  of  the  right  demithorax  either  before  or  behind. 
The  air,  indeed,  seemed  not  to  enter  the  bronchial  tubes  of  the 
right  lung  above  at  all ; and  only  a little  respiration  was  audible 
along  the  back  close  to  the  spine,  and  in  the  lower  region  of  the 
chest.  She  died  about  two  years  after  of  a different  disease,  and 
inspection  presented  the  following  appearances. 

The  whole  of  the  upper  lobe  of  the  right  lung  and  part  of  its 
middle  lobe  was  firm  and  solid,  and  inelastic  like  a mass  of  solid 
flesh.  The  pleura  adhered  behind,  and  partly  on  the  sides,  and  a 
little  anteriorly.  On  dividing  this  portion  of  solidified  lung,  the 
bronchial  tubes  were  found  to  be  closed,  except  at  the  apex  and  near 
the  spine,  where  they  were  still  pervious  for  the  space  of  not  more 
than  half  an  inch.  The  pulmonic  substance  itself  was  firm,  of  a r 
light  red  colour,  but  totally  uncrepitating,  and  did  not  admit  the  jL 
air  from  the  tubes.  It  sunk  in  water  like  a stone.  On  tracing 
the  tubes,  they  seemed  to  be  compressed  together  into  ligaments 
or  cords,  quite  solid  and  impervious ; but  it  was  not  easy  to  say - 
whether  they  had  been  filled  with  matter  effused  from  within  their  ^ 
canals  or  exterior  to  them. 

It  seems  also  impossible  to  doubt  that  when  pneumonia  proceeds 
to  abscess  or  vomica,  it  in  like  manner  entails  obliteration  of  the^ 
bronchial  tubes;  and,  if  the  patient  be  not  destroyed  by  the  dis- 
ease, various  tubes  are  found  obliterated. 


Obliteration  is  also  observed  in  those  cases  in  which  tuberculaF 
masses  are  broke  down  and  expelled  by  expectoration,  whether  any 
attempt  to  close  the  vomica  and  heal  it  is  made  or  not. 

I.astly,  in  the  form  of  pneumonia  denominated  lobular,  or 
where  there  appears  to  be  inflammation  of  the  terminal  ends  of  the 
bronchi,  obliteration  at  these  ends  is  very  common,  in  consequence 
of  effusion  of  albuminous  matter  from  the  mucous  membrane  of 
their  terminal  extremities.  This  effusion  or  deposit,  however,  is 


ft  I 


TRACHEO-BRONCHIAL  MUCOUS  MEMBRANE.  605 

probably  either  the  same  with  the  tubercular  deposit,  or  very  simi- 
lar to  it  in  the  mode  and  situation  in  which  it  takes  place. 

§ 8.  Dilatation  and  Hypertrophy  of  Bronchi. — In  certain  circum- 
stances of  chronic  bronchial  disease  the  bronchi  become  greatly  en- 
larged, and  their  walls  are  thickened,  with  thickening  of  the  mem- 
brane. The  diameter  of  the  tubes  may  be  increased  in  this  state 
to  half  an  inch.  Of  this  lesion  Dr  Carsewell  gives  an  excellent 
representation  in  his  Fourth  Division,  first  engraving  ;*  and  an  in- 
stance is  described  by  Mr  W att  of  Manchester  as  having  been  ex- 
hibited at  the  Pathological  Society  of  that  place.f 

§ 9.  Dilatation  of  the  Bronchial  Tubes. — Of  one  species  of  dila- 
tation I have  already  partially  spoken,  as  taking  place  along  with  ob- 
struction and  obliteration  of  these  canals.  There  is  yet  to  be  noticed 
another,  which,  according  to  my  own  observation,  takes  place  either 
solely  or  principally  in  connection  with  aneurismal  enlargement 
and  dilatation  of  the  aorta  or  innominata.  Of  this  I have  seen  se- 
veral examples ; and  from  these,  especially  one  published,^  I give 
the  following  characters  of  the  lesion. 

The  lesion  is  seated  in  the  right  lung,  the  lobes  of  which  are 
generally  solidified  and  inelastic,  of  a reddish-brown  colour,  and 
loaded  with  blood.  The  middle  lobe  and  the  lower  one  are  gene- 
rally more  completely  and  extensively  solidified  than  the  superior 
lobe ; and  the  affection  appears  often  to  commence  in  the  lower 
lobe,  and  thence  proceed  to  the  middle  and  upper  lobes. 

The  great  change,  however,  is  in  the  bronchial  tubes,  which  in 
all  the  three  lobes  are  greatly  enlarged,  losing  their  conical  figure, 
and  being  converted  either  into  large  cylindrical  canals,  or  tubes 
with  wide  dilated  spaces  in  their  course.  Bronchial  tubes,  which  in 
their  natural  state  are  not  larger  than  crow-quills,  become,  espe- 
cially in  the  lower  and  middle  lobe,  of  the  diameter  of  half  an  inch. 
Besides  this,  at  various  points  in  their  course  they  undergo  still 
greater  dilatation,  so  as  to  form  cavities  communicating  apparently 
with  the  bronchial  tubes,  and  thereby  with  each  other,  but  which, 
when  carefully  examined,  are  seen  to  be  unusually  enlarged  por- 
tions of  the  bronchial  tubes  themselves.^: 

* Illustrations  of  the  Elementary  Forms  of  Disease.  By  Robert  Carsewell,  M.  D. 
Foho.  London,  1838.  Hypertrophy,  Plate  1. 

-|-  London  Medical  Gazette,  Vol.  xxxix.  p.  596.  No.  1009.  April  2,  1847. 

+ Report  on  the  Cases  treated  during  the  Course  of  Clinical  Lectures  delivered  at 
the  Royal  Infirmary  in  the  Session  1832-1833.  By  David  Craigie,  M.  D.,  &c. 
Edinburgh  Medical  and  Surgical  Journal,  I'ol.  xli.  January  1834.  P.  106.  Case  of 
Janet  Waits. 


606 


GENERAL  AND  rATHOLOGICAL  ANATOBIY. 


The  bronchial  tubes  in  \his  state  are  filled  with  thick  opaque  pu- 
riform  or  purulent  matter,  on  the  removal  of  which  the  membrane 
is  seen  to  be  reddened,  softened,  and  thickened. 

In  some  instances  the  dilatation,  though  sufficiently  distinct,  does 
not  proceed  to  the  extreme  degree  already  noticed.  The  bronchial 
tubes  of  the  middle  and  lower  lobes  are  merely  rendered  cylindri- 
cal like  goose-quills,  and  filled  with  a sort  of  viscid  albuminous  a ; 
puriform  matter.  The  lung  is  also  solidified,  and,  losing  its  elas-K,| 
ticity,  does  not  crepitate ; and,  when  divided,  puriform  matter  is-,P 
sues  copiously  from  the  cut  bronchial  tubes. 

This  form  of  dilatation  I have  seen  only  in  cases  of  aneurismal 
tumours  of  the  aorta  and  innominata.  It  appears  to  be  caused  prin- 
cipally  by  the  compression  exerted  on  the  superior  bronchial  tubes  5 
by  the  aneurismal  swelling.  In  the  cases  in  which  I have  observ-%, 
ed  the  lesion,  the  aneurismal  tumour  invariably  compressed  muchy 
the  bronchial  tubes  of  the  upper  lobe,  near  the  mediastinum,  so  as  to  r’ 
flatten  them  and  contract  their  area,  and  prevent  the  free  discharge^"" 
of  the  matter  secreted  by  their  mucous  membrane.  The  matter  ; 
retained  appeared  to  be  one  of  the  causes  of  the  great  dilatation 
produced  in  the  small  tubes  of  the  middle  and  lower  lobes.  , 

At  the  same  time  it  must  be  observed,  that  this  same  compression 
causes  general  inflammation  of  all  the  bronchial  tubes  on  which  it*^  ' 
is  exerted,  and  even  inflammation  of  the  pulmonic  tissue  with  the 
usual  morbid  products. 

In  one  case  the  tumour  was  as  large  as  a good  sized  pippin,  two 
inches  and  a-half  in  diameter,  and  compressed  the  right  bronchus 
and  its  divisions  and  the  mesial  or  internal  margin  of  the  lung. 

In  another  case  the  tumour  was  about  the  same  size,  though  more  , 
ovoidal,  and  it  equally  compressed  the  right  bronchus  and  its  i 
branches.  i 

That  this  dilatation  of  the  bronchial  tubes  proceeds  from  the 
cause  now  specified,  must  be  inferred,  I think,  from  the  fact,  that 
in  the  cases  in  which  it  is  observed,  it  is  generally  in  proportion  to 
the  size,  situation,  and  compressing  powers  of  the  aneurismal  tu-  ; 
mour,  and  that  the  lesion  is  confined  to  the  bronchial  tubes  of  the 
right  lung,  not  affecting  those  of  the  left  lung  at  all. 

I have  no  doubt,  nevertheless,  that  were  the  tumour  to  be  situate 
in  that  part  and  side  of  the  aorta  in  which  it  could  compress  the 
left  lung,  the  same  state  of  the  bronchial  tubes  of  that  organ  would 
be  produeed. 


TRACHEO-BRONCHIAL  MUCOUS  MEMBRANE. 


607 


In  general  this  state  of  the  bronchial  tubes  and  lung  can  be 
known  during  life.  The  voice  is' hoarse,  and  like  that  of  a person 
in  croup.  The  cough  is  peculiarly  hoarse  and  sonorous,  as  if  is- 
suing through  a brazen  tube.  The  difficulty  of  breathing  is  very 
great,  and  often  amounts  to  orthopnoea  ; and  mucous  rattling  is 
heard  in  the  middle  and  lower  part  of  the  right  lung  only,  while  at 
the  upper  region  respiration  is  performed  with  a harsh  croaking 
sound. 

C.  THE  GASTRO-ENTERIC  MUCOUS  MEMBRANE. 

In  the  gastro-enteric  mucous  surface  inflammation  may  take  place 
either  generally  or  partially  ; and  it  affects  either  the  villous  mem- 
brane or  its  follicular  apparatus  or  both. 

§ 1.  CEsophagus. — In  the  oesophageal  mucous  membrane  in- 
flammation seldom  appears,  unless  as  part  of  the  same  process 
affecting  the  stomach  and  bowels  more  or  less  generally.  This 
is  particularly  the  case  in  inflammation  of  the  gastric  mucous  mem- 
brane, with  which  a similar  state  of  the  oesophageal  is  almost  in- 
variably connected.  The  surface  is  red,  injected,  and  more  or  less 
villous,  and  thickened  ; and  the  oesophageal  epidermis  is  occasion- 
ally elevated  into  apthae  or  blebs,  leaving,  when  these  are  removed, 
an  excoriated  or  abraded  surface.  In  the  chronic  form  it  may 
affect  the  mucous  glands,  and  produce  ulceration.  Irregular  patches 
of  the  latter  I have  seen  in  subjects  in  whom  the  colic  membrane  was 
extensively  covered  by  ulcers.  The  cases  described  by  Dr  F.  Sim- 
mons and  Dr  Gartshore  appear  to  have  affected  the  submucous  tissue. 

§ 2.  a.  The  gastric  mucous  membrane  may  be  inflamed  generally 
or  partially.  When  a limited  portion  of  the  villous  membrane  is 
inflamed  the  disease  is  seldom  violent.  The  mucous  membrane  of 
the  inflamed  part  shows  an  unusual  number  of  minute  vessels,  but  is 
rarely  much  crowded.  In  some  instances,  however,  it  is  red  or 
scarlet,  with  vessels  disposed  in  arborescent,  punctular,  or  striated 
fashion  ; and  not  unfrequently  spots  or  patches  of  extra vasated  blood 
are  recognized.  At  the  same  time,  the  substance  of  the  mucous 
coat  is  thicker  than  natural,  of  pulpy  softness,  and  when  attempted 
to  be  detached,  is  readily  lacerated. 

The  gastric  mucous  membrane  is  liable,  nevertheless,  to  a more 
general  inflammatory  process,  in  which  its  surface  presents  a light 
rose-coloured  blush  difiused  all  over,  and  secretes  mucous  or  muco- 
purulent fluid  copiously.  The  mucous  membrane  is  also  pulpy 


608 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


and  softened,  but  not  remarkably  thickened.  This  state  of  tlie 
gastric  membrane,  though  occurring  spontaneously,  may  be  pro- 
duced by  repletion  or  improper  articles  of  food,  and  by  several  of 
the  acrid  poisonous  substances.  Of  this  form  of  gasteria  a good 
delineation  is  given  by  Dr  Armstrong  in  the  second  plate  of  his 
first  Fasciculus. 

b,  Gasteria  psilotica  ; Psilosis. — In  the  persons  of  those  who  have 
long  pined  under  various  chronic  diseases,  the  gastric  mucous  mem- 
brane is  liable  to  a form  of  disease  in  which  some  part  of  it  becomes 
pale  white,  bluish,  rose-coloured,  or  gray,  continuously  or  in  long 
narrow  stripes,  or  irregular  patches  more  or  less  thickly  set.  The 
spaces  so  coloured  are  simply  depressed  beneath  the  level  of  the 
adjoining  membrane,  not  ulcerated,  soft  and  thin,  and  converted 
into  a glairy  semitransparent  pulp.  According  to  M.  Louis,  to 
whom  the  pathologist  is  indebted  for  the  correct  description  of  this 
change,  when  in  narrow  stripes,  it  is  distributed  nearly  uniformly 
over  the  whole  surface  of  the  stomach ; when  continuous,  it  occu- 
pies the  large  extremity  of  the  organ,  is  rarely  confined  to  the  great 
cul  de  sac,  and  in  some  instances  appears  at  once  at  the  cardiac 
and  pyloric  orifices.  The  vessels  of  the  submucous  tissue,  which 
is  generally  sound,  are  large,  distinct,  and  empty.*  F rom  the  few 
instances  in  which  I have  seen  this  change  myself,  I should  say  that 
it  consists  in  removal  of  the  villi  by  some  process  analogous  to 
inflammatory  absorption.  It  is  certain  that  in  the  afiected  patches 
these  processes  are  greatly  less  distinct,  and  often  totally  gone.  I 
may  add  that  this  is  one  at  least  of  the  forms  of  the  change  which 
John  Hunter  describes  as  digestion  of  the  stomach  ;f  and  also  one 
of  these  described  by  Dr  Yellowly,j;  the  greater  part  of  which,  it  is 
to  be  observed,  occurred  in  persons  cut  off  by  pulmonary  consump- 
tion. To  this  head  probably  are  to  be  referred  such  cases  as  that 
recorded  by  Mr  Douglas,  who  found  the  villous  coat  obliterated 
except  near  the  pylorus,  and  the  muscular  absorbed. § The  theory 
of  its  production  is  further  exceedingly  obscure ; and  I abstain  from 
conjecture. 

In  similar  subjects,  but  more  especially  in  the  phthisical,  the  gas- 
tric membrane  is  liable  to  become  occupied  by  minute  roundish^ 
eminences,  not  unlike  granulations  separated  by  superficial  furrows, 

* Memoires  ou  Recherches  Anatomico-Pathologiques.  Pari.*,  1826. 

t Observations  on  certain  parts  of  the  Animal  Economy,  p.  226,  2.31. 

:J:  Medico-Chir.  Trans.  Vol.  iv.  p.  2/1,  5 out  of  20. 

§ Mem.  Med.  Soc.  vol.  iv.  p.  39.5. 


Ml 


GASTRIC  MUCOUS  MEMBRANE — CHRONIC  ULCER, 


609 


with  occasional  points  of  ulceration  round  or  oblong  form,  from 
one  to  several  lines  in  diameter.  The  colour  of  the  membrane  is 
at  the  same  time  reddish,  or  reddish  gray,  always  thickened,  and 
generally  softened,  and  covered  with  much  viscid  mucous.  This 
granular  state  of  the  mucous  membrane  is  most  frequent  in  the 
large  curvature,  and  the  parts  adjoining  to  the  anterior  and  poste- 
rior surfaces,  at  the  pyloric  extremity,  the  small  curvature,  and  the 
great  cul  de  sac,  the  whole  extent  of  which,  however,  is  rarely  af- 
fected.* The  granular  eminences  appear  to  be  swellings  of  the 
mucous  glands,  which  are  most  abundant  in  the  situations  in  which 
it  is  seen. 

c.  Gasteria  Diuturna,  Gasteria  ulcerans^  Gasteria  Helkosis. — 
Chronic  inflammation  of  the  gastric  mucous  membrane  is  much 
more  frequent  than  is  imagined.  The  process  is  in  general  con- 
fined to  one  or  two  small  spots,  which  are  slightly  red,  often  brown 
or  reddish  brown,  rough,  villous,  and  firmer  than  natural.  Of 
these  appearances  the  most  constant  is  the  rough  villous  aspect  and 
firm  consistence,  which  are  at  once  recognized  by  drawing  the 
finger  over  the  part.  The  inflammation  does  not  spread,  but 
gradually  penetrates  to  the  submucous  filamentous  tissue  which  is 
exposed,  and  terminates  in  the  formation  of  an  ulcer  or  ulcers  of 
the  mucous  membrane. 

The  most  usual  appearance  of  these  ulcers  is  that  of  depressed 
breaches  in  the  continuity  of  the  mucous  membrane,  with  a rough, 
brown-coloured  surface,  variable  in  size,  but  generally  small,  af- 
fecting an  irregularly  round  or  oval  shape,  sometimes  angular,  and 
with  edges  smooth,  but  sharp  and  accurately  marked.  This  cha- 
racter, which  is  that  of  a piece  of  the  membrane  completely  cut 
or  scooped  out,  is  certainly  derived  from  the  peculiar  properties 
of  the  mucous  corion,  which  seems  in  ulceration  to  undergo  a 
gradual  process  of  absorption.  When  the  first  minute  percep- 
tible point  of  ulceration  is  formed,  the  edges  are  destroyed  or 
absorbed  in  the  same  gradual  manner,  and  thus  the  vdcer  is  en- 
larged. The  edges  are  in  general  some  shade  of  crimson  or  reddish 
brown,  owing  to  injected  capillaries  of  the  corion  ; but  in  other  in- 
stances the  colour  does  not  differ  from  that  of  the  adjoining  surface. 

Many  of  the  examples  of  this  lesion  have  been  described  as  in- 
stances of  rupture  or  perforation  of  the  stomach  ; and  hence  it  is 
not  easy  to  ascertain  the  exact  state  of  the  villous  membrane  in  the 
* Louis,  Recherches  Anatomico-Pathologiques  siir  la  Phthisie.  Paris,  1825, 

Q q 


610 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


incipient  stage  of  the  disease.  It  is  nevertheless  impossible  to  doubt 
that  these  ulcers,  whether  in  the  state  of  ulcers,  or  appearing  aftei’- 
wards  as  perforations,  must  originate  in  inflammation  which  proba- 
bly attacks  one  point  and  is  circumscribed  to  that,  while  it  is  slow 
in  progress  and  chronic  in  character. 

Instances  of  this  lesion  have  now  become  numerous.  Cases  have 
been  recorded  by  Morgagni,* * * §  Dr  Carmichael  Smyth,!  Gerard,! 
Dr  Baillie,§  Dr  Crampton,  \\  Mr  Travers,1T  Laennec,** * * §§  Dr  Aber- 
crombie,!! Di'  Elliotson,!!  M.  Duparque,§§  M.  Uebersaal,|||l  M. 
Goeppert,1f1F  and  Cruveilhier. 

From  these  cases,  and  seven  which  have  been  observed  and  inspect- 
ed by  myself,***  I conceive  the  following  general  conclusions  re- 
garding the  nature  and  character  of  this  lesion  may  be  established. 

It  is,  in  the  ^rst  place,  remarkable  that  the  majority  of  these 
cases  of  ulcerative  destruction  of  the  mucous  membrane  of  the 
stomach  are  situate  either  in  the  small  arch  of  the  stomach,  or  very 
near  the  small  arch.  In  the  case  by  Dr  Carmichael  Smyth,  it  was 
in  the  anterior  part  towards  the  cardia.  In  the  first  case  by  Ge- 
rard, it  was  in  the  small  arch,  one  inch  from  the  pylorus.  In  his 
fifteenth  case  also,  a circular  hole  was  found  at  the  right  and  an- 
terior side  of  the  small  curvature.  It  is  unnecessary  to  refer  to 
all  his  cases,  because  he  does  not  distinguish  between  simple  in- 
flammatory ulceration  and  that  which  is  the  effect  of  tubercular  de- 
struction and  cancer.  In  the  case  by  Dr  Baillie,  it  was  near  the 
small  curvature  on  its  posterior  side,  about  two  inches  from  the 
cardia.  In  the  case  by  Dr  Crampton,  it  was  at  the  union  of  the 
cardiac  and  pyloric  portions.  In  the  instance  of  the  late  M.  Bec- 
lard,  the  anatomist,  who  had  laboured  under  symptoms  leading  to 

* De  Sed.  et  Caus.  Epist.  xxix.  14.  I am  doubtful  whether  this  case  be  not  the 
result  of  tubercular  ulceration. 

T Medical  Communications,  Vol.  ii.  p.  467. 

J Des  Perforations  Spontandes  de  I’Estomac.  Par  M.  Alexandre  Gerard,  D.  M., 
&c.  Paris,  180.5. 

§ Morbid  Anatomy,  Chap.  vii.  Lond.  1825  ; and  Miscellaneous  papers  and 
Dissections,  p.  199. 

II  Medico-Chirurgical  Transactions,  Vol.  viii.  p.  228. 

^ Ibid.  Vol.  viii.  p.  271.  , u.' 

**  Revue  Medicale,  Mars  1824.  / 

-]-+ Edin.  Med.  and  Surgical  Journal,  Vol.  XXI.  p.  3. 

Medico-Chirurg.  Trans.  Vol.  xiii.  p.  26. 

§§  Archives  Generales,  Vol.  xxvi.  p.  123.  ' 

nil  Ibid.  Vol.  xxvi. 

Ulf  Rust’s  Magazin,  1830.  F.  32.  3.  C. 

»**  Edin.  Med.  and  Surg.  Journal,  Vol.  xliv.  p.  262.  Edinburgh,  1835. 


GASTRIC  MUCOUS  MEMBRANE — CHRONIC  ULCER. 


611 


the  suspicion  of  chronic  inflammation  in  the  gastric  mucous  mem- 
brane, and  in  whom  these  symptoms  had  subsided  under  appropri- 
ate treatment,  after  death  from  disorder  of  the  brain,  a cicatrized 
ulcer  was  found  in  the  small  arch  of  the  stomach  the  size  of  a six- 
pence, about  four  lines  from  the  cardia* 

In  the  cases  by  Ubersaal,  Goeppert,  and  four  of  the  seven  seen  by 
myself,  the  ulceration  was  situate  in  the  small  curvature.  In  two, 
indeed,  of  the  first  three  cases  described  by  me,  the  ulceration  of 
the  villous  membrane  was  bisected  by  the  line  of  the  small  arch. 

In  other  three  cases  examined  by  me,  the  ulcers  were  situate  in 
the  anterior  region  of  the  stomach,  about  midway  between  the 
small  and  great  arch.  In  one  case,  that  of  a young  female  of  23, 
there  were  in  this  situation  two  ulcers,  one  rather  larger  than  a 
sixpenny  piece,  one  less  than  a fourpenny  piece.  The  largest  had 
given  way ; and  the  rupture  was  followed  by  escape  of  the  con- 
tents of  the  stomach,  and  fatal  peritonitis  in  the  course  of  a few' 
hours.  The  patient  was  in  her  usual  health  at  seven  in  the  even- 
ing, and  she  was  found  lifeless,  yet  not  cold,  in  bed  next  morning. 

In  another  case,  which  took  place  also  in  a young  woman  of 
about  22,  the  ulcer  was  situate  in  the  anterior  part  of  the  stomach, 
but  nearer  to  the  pylorus. 

In  the  sixth  case,  which  took  place  in  a boy  of  1 1 years,  who 
had  been  labouring  under  granular  disease  of  the  kidney,  and 
dropsical  symptoms,  extensive  peritoneal  inflammation,  with  copious 
effusion  of  lymph,  had  taken  place  over  the  intestines.  But  it  was 
not  certain  whether  this  had  been  caused  by  perforation  or  not. 
There  was  no  distinct  evidence  of  escape  of  the  contents  of  the 
stomach,  which  contained  a good  deal  of  blood  coagulated  and  se- 
mifluid, which  must  have  escaped  from  some  vessel  or  vessels  open- 
ed in  the  margins  of  the  ulcer. 

Secondly,  Whatever  part  of  the  organ  they  occupy,  the  diflferent 
tissues  are  always  destroyed  in  unequal  degrees ; — the  villous 
membrane  being  most  extensively  destroyed,  the  filamentous  and 
muscular  less  so,  and  the  peritoneal  least.  Indeed,  it  is  by  no 
means  certain  that  the  peritoneal  is  destroyed  by  ulceration,  as  it 
seems  rather  to  give  way  after  the  other  tissues  have  been  removed 
from  it  and  cease  to  support  it,  than  to  undergo  loss  of  substance 
itself. 

Thirdly,  Though  the  ulcers  now  mentioned  resemble  ulcers  in 
other  parts  of  the  body,  they  have  nevertheless  a very  peculiar 
* Billard  de  la  Membrane  Muqueuse.  Paris,  1825.  P.558, 


612 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


character.  The  mucous  membrane  is  always  exactly  destroyed  to 
certain  well-marked  limits ; and  the  edges  which  are  formed  by 
the  mucous  membrane  are  in  all  cases  sharp,  manifest,  and  well 
defined.  They  appear  as  if  some  time  previously  a part  had  been 
cut  or  punched  out  from  the  villous  membrane  with  a sharp  instru- 
ment, and  the  edges  had  healed,  so  as  to  present  a uniform  smooth 
boundary  round  the  excavation  which  had  been  made. 

Fourthly,  It  is  always  possible  to  distinguish  at  one  part  of  the 
ulcer,  viz.  round  its  edges,  whether  perforation  has  taken  place  or 
not,  the  submucous  filamentous  tissue  and  the  muscular  coat,  much 
less  extensively  destroyed  than  the  villous  membrane.  From  this 
it  may  be  inferred,  that  the  process  had  first  attacked  the  villous 
membrane,  and,  after  destroying  that,  had  proceeded  to  the  fila- 
mentous and  muscular.  In  some  instances,  only  a portion  of  the 
villous  coat  is  destroyed,  and  the  bottom  of  the  ulcer  is  then  form- 
ed by  the  filamentous  and  muscular  layers,  yet  comparatively  un- 
injured, In  other  instances,  however,  all  the  tissues  are  destroyed 
down  to  the  peritoneum,  in  which  perforation  takes  place. 

In  the  fifth  place,  the  villous  membrane  forming  the  edges  of 
the  ulcer  is  often  quite  free  from  redness,  vascularity,  or  thickening, 
and  is  always  completely  without  either  tubercular  deposition,  irre- 
gularity, or  hardness,  such  as  might  be  expected  in  scirrhus.  The 
surrounding  structure  of  the  stomach  is  in  appearance  healthy  and 
unchanged.  Sometimes,  however,  the  margins  are  a little  thick- 
ened, firm,  and  sharp,  and  more  or  less  opaque;  and  the  surround- 
ing mucous  membrane  is  for  some  space  thickened  and  of  a deep 
fawn-colour  ; — changes  which  depend  on  effusion  of  lymph  and  the 
afflux  of  blood  to  the  neighbourhood  of  the  ulcer.  It  must  be  ad- 
mitted, in  short,  that  the  destruction  of  the  villous  membrane  of  the 
stomach  must  have  been  the  effect  of  inflammation,  originating  most 
probably  in  the  villous  membrane,  and  giving  rise  to  the  ulcerative 
destruction  when  the  membrane  was  no  longer  able  to  resist  the 
intensity  of  the  action.  This  is  evidently  inflammation  of  the  sub- 
stance of  the  membrane,  circumscribed  in  character  and  chronic  in 
duration.  Is  there  any  reason  to  suppose  that  it  was  the  result  of 
inflammation  of  the  submucous  filamentous  tissue  ? or  do  these  ul- 
cers originate  in  affection  of  the  glands  of  the  stomach  ? 

In  the  sixth  place,  in  all  these  cases  it  is  a common  character, 
that  there  is  at  the  close  of  the  disease,  inflammation  of  the  perito- 
neal membrane,  with  effusion  of  lymph,  in  proportion  as  the  ulce- 
rative process  affects  the  peritoneum. 


GASTRIC  MUCOUS  MEMBRANE — CHRONIC  ULCER.  613 


In  the  seventh  place,  perforation  or  rupture,  though  the  natural 
termination  of  these  cases,  is  nevertheless  not  necessary  to  the  dis- 
ease. Death  may  take  place  by  mere  •peritonitis^  without  effusion 
of  the  contents  of  the  stomach  into  the  abdominal  cavity.  In  this 
case,  the  adjoining  organs  are  generally  applied  accurately  over 
the  part  of  the  stomach  where  the  ulcer  is  situate,  and  by  the  ad- 
hesion effected  by  the  inflammatory  exudation,  perforation  and  es- 
cape of  the  contents  are  prevented.  No  escape  took  place  in  four 
of  the  six  cases  inspected  by  me.  Under  such  circumstances,  there- 
fore, peritoneal  inflammation  is  rarely  general  or  extensive.  When 
perforation  takes  place,  of  course  the  inflammation  is  very  general 
and  intense.  This  result,  however,  depends  much  on  the  position 
of  the  ulcer  or  ulcers.  When  they  are  situate  on  the  anterior  part 
of  the  stomach,  at  some  distance  from  the  small  arch,  at  which  no 
contiguous  organs  are  applied  over  the  stomach,  perforation  and 
escape  of  the  contents  of  the  stomach  are  very  liable  to  ensue. 

In  the  eighth  place,  it  deserves  to  be  particularly  noticed,  that 
this  disease  is  greatly  more  common  in  females,  and  especially 
young  females,  tlian  in  males.  Among  the  six  cases  seen  by  my- 
self three  took  place  in  young  females;  in  those  that  I have  seen 
examined  by  professional  friends  they  were  mostly  in  females.  The 
disease  seems  not  unfrequent  among  female  domestic  servants. 

The  symptoms  produced  by  this  disease  are  not  well  marked. 
In  all  the  cases  almost  which  have  been  recorded,  though  the  pa- 
tients have  not  been  in  perfect  health,  yet  they  have  been  free 
from  any  symptom  calculated  to  excite  apprehension,  and  they  have 
been  in  general  suddenly  and  unexpectedly  surprised  by  death. 

In  the  cases  which  came  under  my  own  observation,  the  indivi- 
duals had  for  a considerable  time  laboured  under  obscure  and  im- 
perfectly marked  dyspeptic  symptoms,  with  loss  of  flesh,  and  in- 
creasing languor  and  weakness.  In  two  of  them  profuse  hemor- 
rhage had  taken  place  from  the  stomach  at  different  times, — 
circumstances  which  were  afterwards  explained  by  the  position  of 
the  ulcer  on  the  line  of  the  coronary  artery.  A similar  source  of 
haematemesis  was  recognized  in  the  case  given  by  M.  Goeppert,  as 
occurring  in  the  person  of  a young  man  who  had  suffered  from 
anorexia  and  tension  at  the  pit  of  the  stomach,  but  without  being 
aggravated  by  pressure. 

Pain  is  by  no  means  a constant  symptom.  In  the  case  given  by 


614 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Dr  C.  Smyth,  the  patient  had  occasional  but  not  severe  pain  at  the 
stomach.  In  that  by  Dr  Baillie,  the  patient  had  violent  occasional 
pain  in  the  scrobiculus  cordis,  with  vomiting,  most  liable  to  ensue 
after  meals.  In  most  of  the  other  cases,  the  sense  of  pain  was 
either  trifling  or  not  uniform.  But  in  all  there  appears  to  have 
been  a sense  of  dull  gnawing  or  aching,  either  constant  or  pretty 
frequent.  In  one  of  the  cases  seen  by  myself,  though  the  patient 
always  complained  of  pain,  it  was  referred  to  a point  deep  in  the 
epigastric  region,  towards  the  spine,— a peculiarity  which  I think 
was  due  to  irritation  of  the  extremities  of  the  nervous  filaments  sent 
along  the  small  arch. 

The  pulse  is  not  much  affected  in  this  disease. 

The  circumstances  now  remarked,  however,  apply  only  to  the 
early  stage  of  the  complaint,  while  it  is  still  confined  to  the  villous 
membrane,  or  at  most  does  not  touch  the  peritoneum.  When  the 
ulcerative  action  penetrates  through  the  gastric  tissues  and  begins 
to  affect  this  membrane,  it  produces  also  slight  and  limited  'perito- 
nitis, which,  if  there  be  other  organs  applied  on  the  part,  tends  to 
protract  the  life  of  the  patient,  and  retard  for  a little  the  approach 
of  the  fatal  event.  With  this  peritoneal  inflammation,  the  pulse 
becomes  quick  and  sharp,  and  the  patient  complains  of  more  or  less 
pain  in  the  epigastric  and  umbilical  regions.  But  when  the  ulce- 
rative destruction  has  reached  the  peritoneum,  the  life  of  the  patient 
hangs  by  a thread.  The  most  casual  occurrence,  as  a fit  of  sneez- 
ing, coughing,  eructation,  or  vomiting,  or,  even  without  these,  the 
distension  of  the  stomach  by  drink  or  by  air  extricated  from  flatu- 
lent food,  may  produce  perforation,  and  cause  the  escape  of  gaseous 
and  fluid  contents  into  the  cavity  of  the  abdomen,  and  general  pe- 
ritoneal inflammation  very  speedily  fatal. 

It  is,  therefore,  too  often  only  at  the  close  of  this  disease  that 
the  practitioner  can  even  conjecture  its  true  nature. 

In  every  case,  however,  in  which  obstinate  dyspeptic  complaints 
are  accompanied  with  a gnawing  sensation,  more  or  less  constant, 
referred  to  the  region  of  the  stomach,  or  occasional  acute  pain, 
with  loss  of  flesh,  weakness  and  languor,  and  with  the  frequent  re- 
jection of  ingesta,  the  presence  of  chronic  inflammation  and  ulcera- 
tion may  be  suspected.  This  conjecture  will  be  converted  into 
certainty,  when,  after  a course  of  such  symptoms,  the  patient  is 
suddenly  and  unexpectedly  attacked  with  feelings  of  faintness  and 
sinking,  acute  pain  generally  radiating  from  the  epigastrium  or 


GASTRIC  MUCOUS  MEMBRANE — CHRONIC  ULCER.  615 


navel,  all  over  the  belly,  pale,  shrunk  features,  small  rapid  pulse, 
followed  by  rapid  breathing  and  cold  extremities ; and  dissolution 
may  then  be  certainly  apprehended. 

This  species  of  gastric  inflammation  and  ulceration  has  been  con- 
founded by  several  authors  with  cancerous  destruction.  From  this, 
however,  it  is  to  be  distinguished  by  the  absence  of  any  considerable 
thickening  or  induration  in  the  vicinity  of  the  ulcer,  or  in  any  other 
part  of  the  stomach,  by  its  presenting  less  intense  gastric  symptoms, 
and  by  its  taking  place  either  principally  in  young  persons,  especi- 
ally young  females,  or  in  persons  of  all  ages ; while  cancer  is  rather 
the  disease  of  declining  years. 

Ulceration  aflFecting  the  mucous  follicles  of  the  stomach  is  some- 
what different.  The  surface  of  the  swelled  follicle  begins  to  be 
perforated  by  innumerable  minute  reddish  points,  which  gradually 
coalesce,  and  when  this  is  completed,  a reddish  brown  I’agged  sur- 
face is  formed. 

Ulceration  often  proceeds,  it  has  been  seen,  by  successive  destruc- 
tion of  the  submucous,  muscular,  and  peritoneeal  coats  to  perfora- 
tion, which  consists  in  the  occurrence  of  a ragged  opening,  through 
which  the  contents  of  the  organ  escape,  and  give  rise  to  secondary 
peritonaeal  inflammation,  which  is  invariably  fatal.  This  accident, 
examples  of  which  are  recorded  by  Morgagni,  Lieutaud,  Carmi- 
chael Smyth,*  Gerard,!  Crampton,f  Travers, § Louis,  and  Dr  Aber- 
crombie, may  take  place  at  any  part  of  the  stomach,  but  appears  to 
be  most  frequent  in  the  space  between  the  great  and  small  arches, 
but  nearer  to  the  former.  In  some  rare  instances,  in  which  adhe- 
sion is  formed  between  an  adjoining  organ  and  the  edges  of  the 
aperture,  the  contents  of  the  stomach  are  prevented  from  escaping, 
and  life  may  be  continued  till  the  progress  of  ulceration  destroys 
a part  where  this  temporary  barrier  cannot  have  place. 

The  most  important  point  to  be  known  is,  that  these  ulcers  may 
be  cicatrized.  Independent  of  the  uncertain  cases  recorded  by  At- 
kinson and  Red,  we  have  an  authentic  and  unequivocal  example  in 
the  person  of  the  late  M.  Bedard.  This  able  anatomist  laboured 
at  one  period  of  his  life  under  obstinate  symptoms  of  gastric  dis- 
ease, the  nature  of  which,  though  uncertain,  seemed  to  partake  of 
chronic  inflammation.  The  symptoms  did  not  give  way  without 

* Med.  Commun.  Vol.  ii.  p.  467. 

t Ues  Perforations  Spontanees  de  I’Estomac.  Paris,  1603. 

$ Trans,  of  the  Association,  Vol.  i.  § Med.  Chir.  Trans.  V ol.  vii. 


616 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


frequent  local  blood-letting,  counter-irritation,  and  tbe  most  rigid 
regimen.  After  death,  there  was  found  in  the  small  curvature, 
about  4 lines  from  the  cardia,  a cicatrized  ulcer,  the  size  of  a 20  sols 
piece,  with  a depressed  surface,  the  middle  of  which  was  traversed 
bya  solid  cellular  band,  on  each  side  of  which  were  two  lacunce  form- 
ed by  peritonaeum.  The  margins  were  neither  red  nor  swollen ; 
and  the  rest  of  the  stomach  was  sound.* 

d.  Solution  of  the  gastrictunics  enfeebled  by  inflammation. — Besides 
the  ulcerative  perforation  now  mentioned,  another  variety  has  beenc" 
described  by  Jaeger  of  Wirtemberg,  Zeller  of  Tubingen,  Cruveil- 
hier  of  Paris,  and  Dr  John  Gairdner  of  this  place,  as  occurring  in 
the  stomach  and  bowels  of  infants  generally  at  the  breast.  From 
the  elaborate  examination  of  this  subject  by  the  latter  author,  it 
appears  that  these  perforations  are  probably  not  the  result  of  pre- 
vious ulceration,  but  are  effected  by  some  solvent  power  of  the  fluids 
after  death  ; that,  nevertheless,  the  parts  so  eroded  and  perforated 
appear  to  undergo  a previous  change  of  structure,  in  consequence 
of  which  they  are  less  able  to  resist  the  solvent  power,  f 

Before  I conclude  this  subject,  I may  remark,  that  in  some  in- 
stances the  mucous  follicles  appear  to  become  enlarged  in  conse- 
quence of  chronic  inflammation,  without  affection  of  the  gastric 
membrane.  A very  good  instance  of  this  change  is  recorded  by  i 
Haller,  who  found  in  the  pyloric  end  of  the  stomach  of  a woman 
of  64,  ten  or  twelve  hemispherical  bodies  like  papilloe,  with  black 
or  perforated  summits,  and  cavities  full  of  purulent  matter.  Though 
the  size  of  these  bodies  was  variable,  the  diameter  of  some  was  three 
lines,  in  others  a full  inch.| 

e.  A particular  cause  of  gastric  mucous  ulceration  has  been  sup- 
posed to  exist  in  certain  substances  belonging  to  the  class  of  corro- 
sive poisons.  That  in  many  instances  these  substances  induce  in- 
flammation, ulceration,  and  erosion  of  the  gastric  tissues,  cannot 
be  denied ; and  this  is  true,  particularly  of  the  concentrated  mine- 
ral acids,  as  is  shown  in  the  cases  and  experiments  of  Tartra,  Or- 
fila,  and  Brodie,  the  cases  and  experiments  recorded  by  Rou- 
pelle,§  and  the  instances,  now  rather  numerous,  in  which  sulphuric 


* De  la  Membrane  Muqueuse  Gastro-Intestinale,  &c.  p.  558.  Par  C.  Billard. 

+ Medico-Chinirgical  Transactions  of  Edinburgh,  Vol.  i.  p.  31 1. 
i Opuscula  Pathologica  Observat.  xxvii. 

§ Illustrations  of  the  Effects  of  Morbid  Poisons.  By  George  Leith  Roupell,  M.  D. 
The  Plates  from  Original  Drawings.  By  Andrew  Melville  M'Whinnie,  M.  R.  C.  L. 
Part  I.  and  II.  London,  18.33.  Folio. 


4 


GASTRIC  MUCOUS  MEMBRANE — MINERAL  ACIDS.  617 


acid  has  been  swallowed  accidentally,  or  used  for^tbe  purpose  of 
self-destruction. 

Though  it  is  true,  however,  that  these  substances  produce  in 
many  instances  inflammation,  and  in  several  corrosion,  it  is  not  es- 
tablished that  they  in  all  cases  cause  ulceration.  It  is  very  doubt- 
ful even  if  arsenic  itself,  to  which  this  property  has  been  often  as- 
cribed, ever  induces  ulceration ; for  in  a large  proportion  of  cases  in 
which  particles  of  the  solid  oxide  have  been  found  in^the  stomach, 
no  ulceration  has  been  recognized.  The  reason  of  this  I conceive 
to  be,  that  death  is  eflfected  by  the  severity  of  the  general  operation 
of  the  agent,  before  there  is  time  for  ulceration. 

From  the  instances  of  deglutition  of  sulphuric  and  nitric  acid 
which  have  fallen  under  my  own  observation,  and  from  the  records 
of  other  cases,  the  following  conclusions  may,  I think,  be  established. 

Is#,  The  first  effect  of  sulphuric  acid  is  evinced  in  its  transit 
over  the  membrane  of  the  mouth,  throat,  and  oesophagus.  It  there 
indurates,  crispates,  and  raises  into  vesications  the  mucous  epider- 
mis, and  giving  it  a brownish  colour  and  greater  firmness.  Nitric 
acid  produces  the  same  effects,  imparting,  however,  a citron  yellow 
colour  to  the  epidermis.  Both  acids  render  the  terminal  boundaries 
of  the  epidermis  at  the  cardia  much  more  distinctly  visible  than  in 
the  natural  state. 

Both  sulphuric  and  nitric  acid  produce  at  the  epiglottis  and  up- 
per part  of  the  larynx  so  much  detachment  of  the  mucous  epider- 
mis with  inflammation  generally,  as  to  give  rise  to  symptoms  of 
laryngitis  and  oedema  glottidis,  much  as  after  the  accidental  swal- 
lowing of  boiling  water.  Even  during  life  the  symptoms  of  gasp- 
ing and  spasmodic  depression  of  the  lower  jaw  are  as  well  marked 
as  in  cases  of  spontaneous  laryngitis,  and  in  most  instances  they  are 
more  intense. 

In  the  stomach  the  effects  vary  as  the  organ  is  empty  or  contains 
articles  of  food. 

If  it  contain  articles  of  food,  these  are  generally  blackened, 
hardened,  and  charred,  as  it  were,  by  the  contact  of  the  acid.  If 
the  organ  be  empty,  or  contain  little  food,  the  parts  touched  by 
the  acid  appear  like  portions  blackened,  indurated,  and  charred. 
The  blood  in  the  vessels  is  coagulated  and  blackened;  and^the 
vessels  appear  as  if  they  had  been  filled  by  a dark-coloured  injec- 
tion which  has  speedily  become  solid.  The  blackened  and  indurat- 
ed patches  vary  in  size  and  shape.  They  may  be  small,  but  most 


618 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


commonly  they  are  large,  as  large,  that  is,  as  a crown  piece  or  a 
half-crown  piece.  Their  edges  are  distinctly  circumscribed.* 

In  cases  in  which  sulphuric  acid  is  swallowed  and  death  follows 
speedily,  the  acid  is  not  only  absorbed  by  the  blood  but  transudes 
through  the  tissues ; and  the  peritoneal  covering  presents  a distinct 
acid  reaction.  The  acid  in  like  manner  acts  on  the  concave  'sur- 
face and  anterior  edge  of  the  liver,  rendering  it  hard  and  friable 
on  the  transverse  arch  of  the  colon,  contracting  that  bowel  and 
rendering  its  tissues  hard  and  thick ; on  the  duodenum,  contracting 
its  calibre  and  rendering  the  coats  firm  and  thick ; and  acting  in  a 
similar  manner  on  the  adjoining  folds  oi jejunum  and  ileum. 

It  occasionally  happens  that  a portion  of  the  stomach  is  dissolved 
and  corroded,  forming  a ragged  irregular  opening ; and  the  con- 
tents escape  into  the  abdominal  cavity.  This  happened  to  a woman 
who  had  committed  double  suicide.  She  had  swallowed  oil  of  vi- 
triol, apparently  without  its  having  been  known.  She  then  cut  her 
throat  with  a knife.  She  was  supposed  to  have  died  of  the  effects 
of  the  wound  in  the  throat ; and  certainly  vessels  enow  were  di- 
vided to  cause  the  loss  of  much  blood ; and  blood  was  found,  as  is 
often  the  case  in  examples  of  cut  throat,  in  the  bronchial  tubes. 
But  besides  this,  there  was  in  the  large  arch  of  the  stomach  a large 
ragged  irregular-shaped  and  dissolved  opening,  which  presented 
all  round  the  usual  charring  and  induration  caused  by  sulphuric 
acid.f 

When  the  mineral  acids  do  not  immediately  kill,They  cause  in- 
flammation of  the  parts  touched.  The  oesophageal  epidermis  is  cast 
off,  and  the  whole  surface  of  that  tube  suppurates  and  secretes 
lymph  and  granulates.  The  mucous  membrane  of  the  stomach  in  | 
like  manner  suppurates,  or  sloughs  and  suppurates,  seci-eting  lymph  K 
and  granulation.  Under  this  process  the  patient’s  life  may  be  pro-  1 
traded  from  five  or  six  weeks  to  two  months,  with  great  suffering,  | 
distress,  and  wasting.  But  death  at  length  takes  place,  and  the  .1 
parts  are  found  in  the  state  now  described. 

The  effects  of  nitric  acid  on  the  stomach  are  very  similar  to  those® 

* Account  of  a Case  of  Suicidal  Poisoning  by  means  of  Concentrated  Sulphuric  .3 
Acid,  with  notices  of  other  cases.  By  David  Craigie,  M.  D.  &c.  Edinburgh  MedicaLi 
and  Surgical  .Journal,  Vol.  hii.  p.  406.  Edinburgh,  1840. 

-)-  Cases  of  Poisoning  by  Arsenic,  Sulphuric  Acid,  and  Muriate  of  Mercury.  By 
Alexander  Watson,  F.  R.  C.  S.  E.  Ibid.  Vol.  liii.  p.  401. 

3 


GASTRIC  MUCOUS  MEMBRANE MINERAL  ACIDS.  619 


of  sulphuric  acid.  But  the  citron  yellow  coloration  of  the  gastric 
tissues  is  here  also  conspicuous. 

The  vapour  of  nitric  acid  also  operates  on  the  organs  of  respi- 
ration. 

Hydrochloric  acid  is  less  frequently  employed,  either  accidentally 
or  intentionally,  apparently  than  sulphuric  acid.  But  its  effects  are 
very  similar.  Crispation  and  detachment  of  the  oesophageal  epi- 
dermis; charring  of  the  interior  of  the  stomach;  blackening  and 
coagulation  of  the  blood  in  the  blood-vessels  ; corrosion  of  the  gas- 
tric tissue ; and  a dark  mottled  appearance  of  the  neighbouring 
viscera ; are  all  lesions  which  have  been  observed  after  deglutition 
of  this  acid.  The  bile  is  rendered  of  a bright  grass  green  wherever 
the  acid  comes  in  contact  with  it.* 

The  duration  of  life  after  deglutition  of  the  concentrated  mineral 
acids,  varies  according  to  circumstances  fi’om  four  or  five  hours  to 
twenty-five  or  thirty  hours. 

The  further  examination  of  this  point,  however,  belongs  to  toxi- 
cology. 

f.  In  many  cases  of  canine  madness  the  oesophageal  and  gastric 
membrane  has  been  found  reddened  and  covered  with  viscid  mucus ; 
(Morgagni,  Baillie,  Bahington,  Ferriar,  Marcet,  Powel,  Pinckard, 
&c.)  and  several  authors  have  here  been  inclined  to  ascribe  the 
symptoms  of  that  disease  to  oesophageal  and  gastric  inflammation. 
Admitting,  however,  that  appearances  of  this  kind  are  sufficient  to 
constitute  spreading  or  diffuse  inflammation  of  the  mucous  surface, 
it  does  not  follow  that  this  is  the  cause  of  the  hydrophobic  symp- 
toms. The  oesophageal  and  gastric  redness  is  not  constant ; and 
its  presence  and  degree,  which  are  secondary,  depend  rather  on  the 
violent  spasmodic  motions  of  the  muscles  of  deglutition  and  the 
diaphragm,  than  on  positive  or  primary  inflammation. 

The  affection  of  the  gastric  mucous  membrane  occurring  in  fever, 
as  remarked  by  Roederer  and  Wagler,  Sarcone,  Pinel,  and  others, 
shall  be  noticed  afterwards. 

§ 3.  The  duodenum  is  liable  to  morbid  lesions  similar  to  those  af- 
fecting the  stomach.  Chronic  inflammation  appears  to  be  the  most 
common  affection  in  that  part  of  the  alimentary  canal.  Under  its 
influence  the  duodenal  mucous  membrane  becomes  firm,  rigid,  and 
a little  thickened.  Its  glandular  apparatus  also  is  liable  to  be  hy- 

* Case  of  Poisoning  by  Muriatic  Acid.  London  Medical  Gazette,  1839,  No.  15. 


620 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


pertrophied,  rendering  the  inner  surface  of  the  tube  irregular  and 
hard. 

Chronic  inflammation  is  liable  to  attack  this  organ  in  the  cir- 
cumscribed form  ; that  is,  affecting  a small  spot  and  proceeding  to 
ulceration  of  the  mucous  membrane,  and  destruction  of  the  whole 
tissues; — producing  perforation  of  a part  of  the  organ  not  ad- 
herent. The  effects  are  quite  similar  to  those  of  ulceration  and 
perforation  of  the  stomach. 

Chronic  thickening  of  the  duodenum  is  liable  to  take  place  at 
any  part  of  the  bowel ; in  some  cases  in  consequence  of  inflamma- 
tion and  congestion,  in  others  in  consequence  of  deposition  of  new 
matter.  If  the  thickening  take  place  near  the  point  where  the 
common  duct  enters  the  bowel,  it  causes  jaundice  often  of  a most 
obstinate  character.  It  is  still  worse  where  the  deposit  is  tubercu- 
lar or  scirrhous.  In  one  case  of  this  kind,  the  jaundiced  colour  of 
the  surface  was  not  only  very  deep,  but  continued  obstinately  to 
the  last.  It  was  found  after  death  that  the  mucous  membrane  of 
the  duodenum  was  the  seat  of  a deposition  of  tubercles  near  and  all 
round  the  orifice  of  the  common  duct ; and  that  these  had  thicken- 
ed the  tissues  of  the  bowel  to  so  great  a degree  as  to  obstruct  en- 
tirely the  orifice  of  the  duct.  The  surface  of  this  deposition  was 
beginning  to  be  ulcerated,  being  irregular  and  abraded ; and,  had 
life  been  prolonged,  the  morbid  process  would  doubtless  have  de- 
stroyed the  tissue  of  the  bowel  and  caused  perforation. 

Any  other  deposit  is  liable  to  produce  tbe  same  results. 

§ 4.  Enteria. — Inflammation  of  the  iliac  mucous  membrane  is 
greatly  more  frequent  than  it  has  been  represented  by  authors. 
Whatever  be  the  influence  of  authority  to  the  contrary,  it  may  be 
shown  that  the  frequent  fluid  alvine  discharges,  to  which  physicians 
give  the  name  of  diarrhoea,  are  in  the  greater  number  of  cases  to 
be  referred  to  inflammation  of  the  mucous  surface  of  the  intestines, 
spreading  over  a considerable  extent,  and  rarely  penetrating  to  the 
submucous  filamentous  tissue. 

Though  it  was  originally  maintained  by  Glisson  on  the  evidence 
of  dissection,  that  in  diarrhoea  the  intestinal  mucous  membrane  is 
inflamed,  and  a similar  idea  was  entertained  by  Baglivi  and  other 
Italian  physicians,  the  facts  on  which  this  opinion  rests,  appear  to 
have  been  overlooked,  amidst  the  zeal  and  ingenuity  with  which 
the  hypothesis  of  inordinate  motion  {motus  ahnormis)  of  the  school 
of  Hoffmann  and  Cullen  was  defended.  Next  to  the  instance  re- 


INTESTINAL  MUCOUS  MEMBRANE. 


621 


corded  by  Morgagni  in  his  own  person  and  others  mentioned  in 
his  31st  epistle,  in  the  Reports  of  Ludovic  Bang  for  1782  and  1787, 
may  be  found  distinct  traces  of  the  opinion  that  intestinal  inflam- 
mation gives  rise  to  diarrhoea.*  Much  about  the  same  time,  (1798,) 
Carmichael  Smyth  conjectured,  “ that  in  diarrhoeas,  from  catching 
cold,  the  villous  or  interior  coat  of  the  stomach  and  intestines  is 
sometimes  slightly  inflamed. ”f  This  conjecture  was  afterwards 
confirmed  by  the  researches  of  Baillie,f  Pinel,§  Hildenbrand,|] 
Broussais,1T  Petit  and  Serres,**  Abercrombie,  Andral,  Latham, ff 
and  lastly  Billard.  The  proofs  collected  by  these  authors  it  is  un- 
necessary to  examine  minutely.  They  establish  indisputably  the 
inference,  that  the  red  or  rose  tint  of  mere  injection  of  the  mucous 
membrane  is  adequate  to  produce  all  the  symptoms  of  diarrhcea 
passing  into  dysentery.  The  state  of  the  intestinal  membrane,  as 
discovered  by  necroscopy,  may  vary  according  to  the  extent  of  the 
disease,  the  kind  of  the  inflammatory  process,  and  the  parts  of  the 
Intestinal  membrane  affected. 

Inflammation  of  the  intestinal  mucous  membrane,  to  be  rightly 
understood,  should  be  studied  both  in  the  villous  membrane  proper, 
{Enteria ; Enteritis  mucosa  ;)  and  in  the  intestinal  follicles,  iso- 
lated and  agminated;  (^Adenitis;  Adeno-enteria.) 

a.  In  the  villous  membrane  proper,  the  process  is  known  by  red- 
ness and  vascularity,  increased  secretion  of  viscid  jelly-like  mucus, 
which  is  often  very  adherent,  and  sometimes  tinged  with  blood, 
sometimes  with  a proportion  of  albumen,  so  as  to  form  false  mem- 
brane, and  generally  some  thickening  and  roughening  of  the  mem- 
brane. This  is  commonly  a diffuse  or  spreading  form  of  inflam- 
mation, and  in  characters  acute. 

b.  Adenitis ; Adeno-enteria.  Follicular  inflammation.  Dothinenteri- 
tis. — The  intestinal  follicles  are  subject  to  at  least  two  forms  of  in- 

* Selects  Diarii  Nosocomii  Regii  Hafniensis,  Auctore  Frederico  Ludovica  Bang. 
Vol.  i.  p.  47,  Vol.  ii.  and  233,  314,  360,  361. 

t Medical  Communications,  Vol.  ii.  p.  210. 

J “ It  does  not  always  happen,”  says  BailUe,  “ when  a person  has  died  from  fatal 
purging,  that  there  are  ulcers  in  the  intestines.  In  two  cases  which  I have  opened  of 
persons  who  died  from  this  complaint,  the  small  intestines  were  inflamed,  so  as  to  pre- 
sent the  appearance  of  distinct  vessels,  the  small  branches  of  arteries  curling  most 
beautifully  at  the  outer  surface  of  the  intestine  filled  with  florid  blood,  and  the  vUlm.is 
coat  heing  slightly  red." — Dissections,  &c.  p.  218. 

§ Medecine  Clinique  et  Nosographie  Philosophique,  Tom.  ii. 

II  Ratio  Medendi  in  Instit.  Clinico.  If  Phlegmasies  Chroniques. 

**  Traite  de  la  Fievre  Entero-Mesenterique.  8vo.  Paris,  1813. 

tt  An  Account  of  the  Disease  lately  prevalent  at  the  General  Penitentiary.  By  P. 
M.  Latham,  M.  D.  &c.  Lend.  1825. 


622 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


flammatory  enlargement.  In  one  the  mucous  membrane  is  mostly 
affected.  It  swells  up,  becomes  dry  at  first,  then  is  covered  with 
viscid  thick  mucus  adherent  to  it,  while  the  pore  of  the  follicle  is 
more  or  less  obstructed  in  consequence  of  tbe  swelling.  When 
this  continues  long,  it  is  liable  to  induce  abrasion  of  the  mucous 
membrane  or  even  ulceration.  Yet  this  does  not  appear  often  to 
take  place  in  this  sort  of  affection  of  the  follicles.  The  swelling 
may  subside,  and  the  follicle  or  follicles  recover  their  previous  ap- 
pearance and  qualities.  , 

In  the  second  form,  in  which  the  fine  cellular  tissue  is  most  af- 
fected, it  is  very  different.  The  tissue  is  raised  and  swelled  out, 
becomes  firm,  tough,  and  often  assumes  a buff  or  yellow  colour, 
which  shows  that  it  is  dying  or  dead.  In  short  this  follicular  cel- 
lular tissue  is  very  easily  killed,  and  then  forms  a slough  below  the 
mucous  membrane.  The  latter,  however,  being  deprived  of  its 
support  and  nutrition,  likewise  dies,  is  cast  off  as  a superficial  slough, 
while  below  there  is  one  more  deep.  This  also  is  cast  off,  and  a 
deep  ulcer  is  left,  which  is  almost  invariably  very  difficult  to  be 
healed,  and  which  often  does  not  heal,  but,  by  weakening  the 
bowel,  causes  perforation  of  the  peritoneal  coat. 

These  are  forms  of  inflammation  comparatively  chronic,  that  is, 
lasting  from  three  to  six  weeks. 

1.  The  simplest  form  is  that  in  which  the  mucous  surface  is 
light  reddish,  or  rose-coloured  over  a large  extent, — an  appearance 
which  depends  on  superficial  injection  of  the  villous  membrane. 
The  villi  are  red,  and  more  or  less  gorged  with  blood.  This  state, 
besides  producing  copious  mucous  or  sero-gelatinous  discharges, 
is  very  often  the  pathological  cause  of  intestinal  hemorrhage.  In 
some  instances  it  is  shaded  from  a light  rose  to  blood-colour  or 
wine-coloured  crimson. 

2.  The  intestinal  membrane  may  be  marked  by  redness  disposed 
in  various  forms,  arborescent,  asteroid,  or  punctular,  or  in  slender 
linear  streaks.  These  appearances  may  occur  independent  of  in* 
flammation,  as  an  effect  of  transudation,  or  stagnation  during  the 
last  hours  of  existence  or  after  death,  and  should  therefore  be  dis- 
tinguished from  the  same  forms  of  redness  in  connection  with  the 
inflammatory  process,  when  they  indicate  a slight  or  incipient  form 
of  it. 

3.  A common  form  is  in  red  or  brown  patches,  irregular  in  size 
and  shape,  with  sensible  elevation  above  the  surrounding  mem- 
brane, forming  a sort  of  puffy  swelling,  the  surface  of  which  is 
rough  and  irregular,  and,  though  not  hard,  void  of  its  natural  feel. 


INTESTINAL  MUCOUS  MEMBRANE — FOLLICULAR  DISEASE.  623 

Though  these  patches,  which  are  in  the  follicles  isolated  and  agmi- 
nated,  may  occur  in  any  part  of  the  small  or  large  intestine,  they 
are  most  common  at  the  termination  of  the  ileum,  in  which  they  are 
seated  in  the  agminated  patches  of  glands,  and  the  beginning  of 
the  colon,  where  they  are  in  isolated  follicles.  F rom  petechial  and 
ecchymotic  blotches,  with  which  they  are  liable  to  be  confounded, 
they  may  be  distinguished  by  the  blood  being  observed  in  pieces 
of  intestine  held  up  to  the  light  to  be  still  contained  within  vessels- 
(Latham.)  These  red  patches  are  exceedingly  prone  to  proceed 
to  ulceration,  which  takes  place  in  one  or  more  points  near  their 
centre,  and  by  extension  and  coalition  produce  in  no  long  time  a 
breach  in  the  continuity  of  the  mucous  corion  equal  in  size  to  the 
original  patch.  This  is  the  form  of  disease  described  first  by  Frost, 
then  by  MM.  Petit  and  Serres  under  the  name  Entero-mesenteric 
fever,  and  which,  there  is  reason  to  believe,  is  occasionally  epidemic 
in  Paris.*  Of  the  same  nature  is  the  disease  which  was  prevalent 
in  the  Millbank  Penitentiary  during  1822  and  1823.  According 
to  the  description  of  Dr  Latham,  the  patches,  which  most  frequently 
were  circular,  and  not  exceeding  the  diameter  of  a pea,  were  dispersed 
at  intervals  through  the  whole  tract  of  the  intestines.  These  were 
evidently  in  the  isolated  follicles.  When  larger  and  more  irregu- 
lar, they  appear  to  have  been  the  result  of  the  coalescence  of  seve- 
ral small  patches ; and  were  most  likely  in  the  agminated  glands. 
The  transition  to  ulceration  in  this  instance  consisted  in  the  redden- 
ed mucous  membrane  becoming  elevated,  rough,  and  unequal  to 
the  touch,  and  in  erosion  taking  place  at  several  points.f 

4.  A considerable  extent  of  the  membrane  may  be  diffusely  red 
or  reddish  brown,  or  with  a general  rose-coloured  ground  may 
present  red  or  brown  patches  of  a more  intense  tint.  The  mem- 
brane is  at  the  same  time  soft,  friable,  pulpy,  and  often  thickened ; 
the  mucous  glands  are  enlarged  and  reddish ; and  the  membrane 
is  covered  more  or  less  extensively  by  thick,  semi-opaque  viscid 
mucus  of  a reddish  or  wine-eoloured  tint.  This  form  of  the  dis- 
ease is  also  said  to  proceed  to  ulceration.  When  it  does  so,  the 
process  takes  place  not  only  in  spots  and  patches  of  the  mucous 
membrane,  but  in  the  follicles,  which  are  converted  into  a number 
of  oval  reddish-brown  ulcers. 

5.  Part  of  the  intestinal  mucous  membrane  may  present  nume- 
rous vesicular  or  pustular  elevations,  not  unlike  thrush  vesicles 

* Traite  de  la  Fievre  Enteromesenterique,  p.  13.  Paris,  1813. 

t An  Account  of  the  Disease,  &c.  p.  48. 


624 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


{aphth(B\  which  may  terminate  in  the  formation  of  abi'aded  spots 
or  minute  ulcers.  Excoriation  and  abrasion  is  mentioned  by  va- 
rious authors ; but  I think  none  of  them  distinguish  between  this 
and  ulceration,  of  which  I regard  it  as  the  incipient  stage.  Abra- 
sion consists,  properly  speaking,  in  the  removal  of  epidermis ; but 
as  the  existence  of  this  in  the  gastro-enteric  membrane  is  proble- 
matical, it  may  be  doubted  whether  there  is  other  abrasion  than 
what  I now  admit.  These  abraded  spots  or  minute  ulcers  appear 
to  me  to  be  the  apices  of  the  isolated  follicles  proceeding  to  ulce- 
ration. 

6.  In  certain  forms  of  intestinal  inflammation,  the  morbid  pro- 
cess appears  in  the  shape  of  spheroidal  or  conoidal  circumscribed 
eminences,  which  are  red,  fungous,  and  irregular,  and  form  con- 
spicuous prominences  of  the  mucous  membrane.  These  bodies,  which 
thus  resemble  pustules,  and  are  surrounded  by  a red  hoop  (areola)^ 
consist  in  inflammation  of  the  isolated  mucous  follicles  of  Peyer, 
as  represented  by  MM.  Bretonneau  and  Trousseau,  and  many 
subsequent  observers.  They  are  often  much  elevated  above  the 
adjoining  mucous  membrane,  not  unlike  broad  circular  mushrooms, 
and  are  then  sometimes  named  fungi.  There  is  no  doubt,  never- 
theless, that  they  consist,  as  above  described,  of  the  thickened  folli- 
cular cellular  tissue,  with  morbid  secretions  in  the  apex,  and  they 
are  tinged  with  the  colouring  matter  of  the  excrement.  Accord- 
ing to  the  former  of  these  observers  especially,  this  follicular  in- 
flammation, passing  occasionally  to  ulceration,  is  a most  frequent 
form  of  intestinal  disease  not  only  primary,  but  occurring  in  the 
course  of  fevers.  Its  most  constant  and  frequent  locality  is  the  3, 
6,  or  10  last  inches  of  the  ileum,  where  the  agminated  patches 
are  largest,  and  a long  space  of  the  ileum  consists  of  agminated 
follicles  without  interruption ; and  when  it  affects  the  colon  it  is 
near  the  ileo-coecal  valve,  being  on  both  sides  of  this  point  much 
more  confluent  than  at  greater  distances.  This  form  of  intestinal 
inflammation  M.  Bretonneau  denominates  dothinenteria  {hohve  pus- 
tula,  and  ivn^ov  intestinum.')* 

Any  one  of  these  forms  of  morbid  condition  may  produce  all  the. 
phenomena  of  diarrhoea  or  even  dysentery.  The  most  uniform  and 
remarkable  eflPect,  however,  is  after  the  first  discharges  of  feculent 
matter  to  cause  abundant  excretion  of  viscid  mucous  matter,  which, 
though  fluid  when  discharged,  undergoes  a species  of  coagulation 
* Archives  Generales,  Tome  x.  1826.  P.  67  and  169. 


INTESTINAL  MUCOUS  MEMBRANE FOLLICULAR  DISEASE.  625 

not  unlike  jelly.  This  may  be  easily  recognized^  even  when  mix- 
ed with  feculent  matter.  It  is  free  from  the  peculiar  offensive 
odour  of  the  latter ; and  it  appears  to  contain  a proportion  of  al- 
buminous or  gelatinous  matter,  or  both. 

Ulceration  of  the  mucous  follicles  is  very  common  after  the  dis- 
ease in  any  of  the  above  forms  has  subsisted  long.  This  was  seen 
in  those  of  the  duodenum  by  Brunner,  in  those  of  the  ileum  by 
Lecat,  Prost,  Petit,  and  Serres,  Bretonneau,  and  Trousseau,  Bil- 
lard,  and  Dr  Bright  This  form  of  ulceration  is  invariably  more 
complicated  and  more  difficult  of  cure  than  simple  ulceration  of 
the  villous  membrane.  The  latter,  indeed,  without  affection  of  the 
follicles,  is  so  rare  that  its  existence  may  be  questioned. 

To  render  the  history  of  inflammation  of  the  intestinal  mucous 
membrane  and  its  follicles  complete,  I feel  it  necessary  to  take  a 
general  view  of  the  disorder,  as  it  takes  place  at  different  periods 
of  life  and  in  different  circumstances;  and  though  in  this  view  I 
shall  not  disregard  the  observations  and  descriptions  of  others,  yet 
I deduce  it  principally  from  the  results  of  personal  observation  con- 
tinued over  a long  period  of  years. 

1.  Chronic  inflammation  may  attack  the  mucous  follicles  of  the 
ileum  at  six  weeks  after  birth,  at  three  months,  at  six  or  eight 
months,  or  at  twelve  months,  or  two  years  after  birth.  After  the 
latter  period  it  is  less  frequent,  but  may  take  place  under  circum- 
stances presently  to  be  mentioned.  The  earliest  period  at  which  1 
have  observed  the  disease  after  birth  was  six  weeks.  And  in  the 
case  to  which  1 allude,  it  must  be  observed,  that  the  disease  had 
been  present  for  three  or  four  weeks ; so  that  it  may  be  allowed 
that  it  commences  as  early  as  two  or  three  weeks  after  birth. 

The  aggregated  patches,  which  are  generally  more  distinct  in  the 
infant  than  in  the  adult,  are  elevated,  with  rough  prominent  edges, 
rough  surfaces,  so  uneven  with  elevations  and  depressions  that  they 
have  been  supposed  to  be  ulcerated,  and  they  have  been  in  this 
condition  by  some  supposed  to  be  in  a state  of  ulceration.  When, 
however,  the  surface  is  carefully  cleansed  by  water,  it  is  seen  that 
it  is  merely  irregular,  rugose,  here  prominent  and  elevated,  there 
depressed ; and,  in  short,  swelled  or  in  a state  of  inflammatory  con- 
gestion. 

The  reason  of  this  irregularity  is  that  the  inflammatory  conges- 
tion and  injection  affects  mostly  the  follicular  cellular  tissue,  which 
then  rising  up,  where  it  most  easily  does  so,  causes  the  elevations ; 

R r 


626 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


while  the  intermediate  points,  at  which  it  does  not  readily  rise,  form 
the  hollows  and  depressions. 

This  state  of  the  ileal  follicles  may  last  for  weeks,  coming  and 
going,  or  appearing  and  subsiding  alternately.  It  may  take  place 
in  consequence  of  improper  food,  but  seems  also  to  occur  sponta- 
neously or  at  least  without  evident  cause.  It  is  common  in  infants 
fed  by  the  hand  or  other  unnatural  modes ; and  is  often  induced 
at  the  period  of  weaning,  if  care  be  not  taken  to  effect  that  change 
gradually.  When  it  has  been  once  commenced  it  is  liable  to  recur. 

Follicular  irritation  and  enlargement,  if  not  proceeding  to  much 
thickening  and  to  ulceration  of  the  surface,  may  subside,  and  leave 
the  membrane  in  a healthy  state.  Children  who  have  it  are  liable 
to  diarrhoea  in  fits,  or  are  said  to  have  irritable  bowels ; but  as  the 
follicles  return  to  their  natural  condition,  this  symptom  disappears.' 

When  it  continues  long  or  recurs  frequently,  and  gives  rise  to 
frequent,  habitual,  or  violent  diarrhoea,  the  follicles  are  thickened ; 
and  on  the  apices  of  several  of  them  small  ulcers  are  formed.  But 
even  without  ulceration  it  may  prove  fatal  by  the  extent  over  which  j 
it  is  diffused,  the  over-action  and  irritation  of  the  intestines,  and  the 
violence  of  the  general  symptoms,  with  its  wasting  effects  on  the 
function  of  nutrition.  It  is  usually  observed  in  cases  thus  termi- 
nating, that  numerous  invaginations  have  taken  place  in  the  bowel, 
each  invagination  being  formed  over  the  site  of  an  enlarged  aggre- 
gated  patch.  Infants  and  young  children  with  this  disorder  are  JF 
sometimes  cut  off  suddenly,  most  usually  with  symptoms  of  crowing  ^ 
inspiration;  and  spasmodic  contraction  of  the  thumbs,  fingers,  and 
toes.  In  other  cases  symptoms  of  enteritis  or  ■peritonitis  with  ob- 
stinate constipation  often  take  place ; and  then  ulceration  is  found  et;;. 
to  have  extended  to  the  submucous  cellular  tissue  and  the  perito-?^ 
naeum. 

2.  Follicular  inflammation  may  take  place  at  a subsequent  period, 
that  is,  at  periods  after  infancy,  and  between  the  third  and  fifteenth 
year,  or  even  at  later  periods. 

Though  this  disease  may  come  on  in  various  modes  at  the  time 
of  life  now  referred  to,  the  most  usual,  at  least  between  three  and 
seven  or  eight  years,  is  the  following. 

The  patient  is  unwell,  languid,  with  hot  skin,  especially  at  night; 
the  tongue  a little  furred;  the  pulse  quicker  than  usual  (90,  100, 
110);  and  the  appetite  impaired,  with  thirst.  Sleep  is  disturbed 
and  unrefreshing ; the  patient  starts  and  is  alarmed  ; and  awakes 


'i 


INTESTINAL  MUCOUS  MEMBRANE — FOLLICULAR  DISEASE.  627 

in  the  morning  generally  more  fatigued  and  exhausted  than  at 
night.  Yet  there  are  no  very  conspicuous  or  prominent  symp- 
toms which  denote  derangement  or  disorder  of  a particular  texture 
or  region.  This  state  of  matters  may  proceed  for  8,  10,  or  12 
days.  The  bowels  are  then  observed  to  be  irregular ; sometimes 
constipated ; more  frequently  slightly  loose.  In  a few  cases  uneasi- 
ness is  observed  or  felt  in  the  umbilical  or  the  right  iliac  region,  or 
in  both.  The  umbilical  region  may  be  somewhat  distended ; and 
beneath  the  fingers  air  is  felt  moving  in  that  region,  or  in  the  right 
iliac.  Feverishness  continues,  and  is  usually  aggravated  in  the 
latter  part  of  the  day  and  at  or  during  night.  At  length  pain  is  felt 
in  the  belly,  generally  about  the  right  iliac  region  or  the  umbilical ; 
and  this  may  increase  to  symptoms  of  enteritis  or  peritonitis.  Diar- 
rhoea stops ; vomiting  takes  place ; and  the  bowels  are  obstinately 
bound,  while  the  abdomen  is  swelled,  painful,  and  tympanitic. 

Tbe  disease  usually  under  these  circumstances  terminates  fataF 
ly  ; and  the  intestinal  mucous  membrane  and  follicles  are  found  in 
the  following  state. 

Much  viscid  mucus  adheres  to  the  villous  membrane,  and  more 
especially  to  the  aggregated  patches.  When  this  is  removed,  the 
patches  are  observed  elevated,  roughened,  and  indurated  in  various 
degrees.  In  some  the  elevation  is  moderate ; in  others  it  is  great 
and  perceptible,  giving  them  the  aspect  of  pustular  eminences,  or 
rendering  them  like  buttons  on  the  villous  membrane.  Usually 
this  considerable  elevation  depends  on  thickening  and  death  of  the 
follicular  cellular  tissue,  which  is  hard,  friable,  and  of  a buflP  or 
yellow  colour.  In  certain  points  the  mucous  membrane  is  castoff, 
disclosing  small  ulcers ; the  base  of  which  is  sometimes  the  yellow 
thick  dead  tissue  already  mentioned,  sometimes  the  muscular  and 
peritoneal  coat.  These  ulcers  evidently  take  place  in  individual 
follicles ; but  by  two  or  more  coalescing,  two  or  more  small  ulcers 
may  be  converted  into  one  large  one.  The  adjoining  intestinal 
membrane  is  occasionally  but  not  always  thickened ; and  sometimes 
vessels  are  seen  traversing  it  to  the  patch  or  patches  most  thickened. 
The  mesenteric  ganglions  opposite  are  enlarged  in  various  degrees 
and  to  different  extent.  At  some  points  a whole  cluster  of  glands 
enlarged  is  presented  ; at  others,  two  or  three  are  enlarged  but  se- 
parate. 

In  extreme  cases  albuminous  exudation  covers  the  peritoneum 
corresponding  to  the  patches  or  the  ulcers ; and  the  peritoneum 
has  in  certain  cases  given  way  previous  to  deatii,  allowing  the  par- 


628 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


tial  escape  of  the  contents  of  the  bowel,  and  followed  by  effusion  of 
sero-albuminous  fluid  from  the  internal  or  free  surface  of  the  peri- 
tonaeum. 

3.  In  certain  cases  the  isolated  follicles  are  the  seat  of  chronic 
inflammation,  either  alone  or  along  with  the  aggregated  follicle. 
In  either  case  they  present  the  appearance  of  pustules  a little  ele- 
vated, or  fungous-looking  flat  tubercular  bodies.  These  isolated 
follicles  pass  through  the  changes  already  mentioned  in  proceeding 
to  ulceration.  In  the  form  of  pustules  they  have  been  repeatedly 
mistaken  for  variolous  pustules ; and  hence  it  has  been  said,  that 
they  are  sraall-pox  in  the  intestinal  mucous  membrane. 

A peculiar  sort  of  broad  elevated  button-like  appearance  is  oc- 
casionally seen  in  the  intestinal  mucous  membrane  in  this  disorder. 
The  individual  bodies  are  about  two  lines  broad,  sometimes  three, 
irregularly  circular,  with  flat  tops.  They  are  evidently  raised  above 
the  level  of  the  surrounding  mucous  membrane,  and  sometimes 
their  mai’gins  project  over  the  latter.  The  tops  are  fungous-look- 
ing and  rough,  and  of  a fawn  or  dirty  yellow  colour ; and  it  seems 
as  if  the  whole  follicular  mucous  membrane  had  become  thickened 
and  hypertrophied.  This  is  the  result  of  a more  chronic  affection 
than  the  one  already  described.  Occasionally  these  fungous-look- 
ing bodies  are  seated  in  the  isolated  follicles  ; and  sometimes  in  the 
agminated  follicles. 

4.  The  disease  now  described  may  take  place,  as  already  stated,  as 
a mere  intestinal  affection.  Often,  however,  it  is  either  connected 
with  fever,  or  it  is  an  effect  of  the  operation  of  the  febrific  poison. 
In  children  and  young  persons  it  is  often  connected  with  the  fever 
described  as  intestinal  remittent  fever.  In  adults  it  takes  place 
along  with  fever  which  has  been  by  several  observers  described  as 
typhous  fever.  But  when  it  was  manifest  that  typhous  fever,  in  the 
great  majority  of  cases,  took  place,  and  continues  to  take  place, 
without  affection  of  the  intestinal  follicles,  the  fever  in  which  this  fol- 
licular disease  was  said  to  take  place  was  denominated  typhoid  fever. 

The  truth  is,  that  the  disease  takes  place  in  a fever  which  may 
present,  according  to  its  treatment,  typhoid  symptoms  during  the 
second  septenary  period,  or  rather  towards  the  close  of  that  period. 
But  the  fever,  in  which  it  most  commonly  takes  place,  is  a remit- 
tent fever,  with  evening  or  afternoon  exacerbations ; and  the  per- 
sons most  usually  affected  are  children  from  5 to  10,  or  young  per- 
sons in  general  under  the  30th  year  of  age.  The  disease  is  much 
more  common  in  certain  localities  than  in  others.  In  Paris  it  seems 

4 


IXTESTINAL  MUCOUS  MEMBRANE — PERFORATION.  629 


frequent,  but  affects  mostly  persons  coming  from  the  provinces.  In 
London  it  is  also  not  uncommon.  In  Manchester  I have  seen  it 
affecting  the  Irish  labourers.  In  Edinburgh  it  is  not  very  com- 
mon ; and  a physician  treating  from  200  to  300  patients  in  the 
course  of  the  year  my  see  not  above  three  or  four  cases,  and  only 
one  of  these  fatal.  In  certain  seasons  it  is  more  common  than  in 
others.  Thus  several  cases  took  place  in  the  winter  of  1842-1843  ; 
and  a few  cases  took  place  in  the  end  of  1845  and  beginning  of 
1846.  At  the  close  of  the  latter  year  it  was  again  appearing. 

In  Edinburgh  it  is  seen  in  railway  labourers,  and  persons  en- 
gaged in  similar  out-door  labour. 

In  Glasgow  it  is  more  frequent  than  in  Edinburgh,  and  is  seen 
mostly  among  the  Irish. 

It  appears  to  me  not  to  be  contagious,  but  to  affect  spontane- 
ously, or  in  consequence  of  causes,  not  easily  determined,  the 
persons  attacked.  From  the  testimony  of  various  foreign  observ- 
ers, as  Frenzel,  Ebel,  Grossheim,  Stannius,*  Chomel,|  Lesser,f 
and  Cramer,  § it  appears  to  depend  either  on  telluric  miasma,  or  on 
some  atmospheric  conditions. 

c.  Perforation. — Though  any  part  of  the  small  intestine  from  the 
duodenum  to  the  caecum  may  be  the  seat  of  ulcers,  they  are  most 
numerous  and  largest  in  the  lower  part  of  the  ileum.  In  this  part 
of  the  tube  the  ulcerative  process  may  advance  so  far  as  to  affect 
the  submucous  tissue,  the  muscular  layer,  and  the  subserous  tissue, 
upon  which  the  peritonaeum  generally  gives  way,  and  laceration  or 
perforation  takes  place.  That  the  peritonaeum  is  removed  by  ab- 
sorption, or  rather  gives  way  when  no  longer  supported  by  the  col- 
lateral tissues,  may  be  inferred  from  the  fact  observed  by  M.  Louis, 
to  whom  we  are  indebted  for  the  best  and  fullest  account  of  this 
accident ; — that  the  margin  of  the  ulcers  in  which  perforation  takes 
place  is  sharp  and  clean ; that  the  mucous  and  submucous  tissue 
are  destroyed  nearly  to  the  same  extent ; and  that  the  muscular  is 
less,  and  the  peritonaeum  scarcely  at  all  destroyed. 

The  effect  of  perforation  is,  as  in  the  case  of  the  stomach.  Is#, 

• Edinburgh  Medical  and  Surgical  Journal,  Vol.  xlviii.  p.  145. 

•)•  Lefons  de  Clinique  Medicale,  faites  a L’Hotel  Dieu  de  Paris.  Par  le  Profes- 
seur  A.  F.  Chomel.  Paris,  1834  ; and  Edinburgh  Medical  and  Surgical  Journal,  Vol. 
xhx.  p.  492,  and  1.  p.  175. 

+ Die  Entzundung  und  Verschwarung  der  Schleimhaut  des  Verdauungs  Kanales  ala 
selbstandige  Krankheit,  dargestellt  von  Ferdinand  Lesser.  Berlin,  1830.  8vo.  Mit 
Kupfertafeln. 

§ Der  Abdominal  Typhus.  Monographische  Skizze.  Von  Dr  F.  Cramer.  Caasel, 
1840.  8vo.  ss.  128. 


630 


GENERAL  AND  PATHOLOGICAL  AlSfATOMY. 


escape  of  the  intestinal  contents  to  a greatei'  or  less  extent ; 2J,  the 
development  of  peritoneal  inflammation,  with  albuminous  deposi- 
tion on  the  peritoufEum.  The  period  which  elapses  between  the 
commencement  of  ulceration  and  the  completion  of  erosion  varies 
in  different  cases.  According  to  the  observations  of  Louis,  already 
quoted,  it  may  be  inferred  that  in  a space  varying  from  12  to  25 
days,  the  ulcer  or  ulcers  may  effect  destruction  of  the  intestinal 
tunics.  The  occurrence  of  the  final  laceration  of  the  peritoneal 
coat  may  be  conjectured  by  the  patient  experiencing  all  at  once  in 
the  belly  intense  tearing  pain,  aggravated  by  pressure,  speedily 
followed  by  shrinking  of  the  features,  voiniting,  &c.  which,  con- 
tinuing with  almost  incessant  severity  from  20  to  54  hours,  denote 
intense  peritoneal  inflammation  terminating  in  death.  In  one 
case,  which,  however,  must  be  regarded  as  an  exception,  life  was 
continued  for  seven  days  after  the  appearance  of  symptoms  of  per- 
foration. 

d.  Enteria  mollescens. — Under  this  head  may  be  placed  a change 
observed  by  Louis  in  the  ileum  of  many  persons  cut  off  by  phthisis 
and  other  chronic  diseases.  It  consists  in  the  mucous  membrane  be- 
coming exceedingly  soft,  almost  like  mucus  or  jelly,  sometimes  thicker 
than  natural,  and  sometimes  redder.  In  the  instances  in  which  I 
have  observed  this  change  in  phthisical  subjects,  the  intestinal  villi 
were  less  distinct  than  natural.  But  whether  this  arose  from  re- 
moval of  these  bodies  or  from  the  pulpy  swelling  of  the  mucous 
corion,  or  from  absolute  disorganization,  I have  not  been  able  to 
determine.  It  is  rarely  continuous,  and  occurs  chiefly  in  large 
patches,  which  occupy,  however,  the  whole  circumference  of  the 
bowel. 

§ 5.  Chronic  ulceration, — To  this  head  I refer  a form  of  disease 
of  which  I have  seen  several  instances  in  children  labouring  under 
symptoms  of  mesenteric  wasting  ; (tabes.')  I have  no  doubt  that  it 
commences  in  inflammation  of  the  mucous  membrane,  or  rather  of 
the  agminated  follicles  ; but  as  it  was  found  in  the  cases  to  which 
I allude  in  the  form  of  ulcerated  patches,  I prefer,  for  the  sake  of 
obvious  and  easy  distinction,  to  designate  it  as  above.  In  the  best 
marked  instance  in  which  I have  seen  it,  and  the  preparation  of 
which  is  before  me,  it  occurred  in  the  form  of  three  large  bands 
near  the  lower  end  of  the  ileum,  extending  transversely  round  the 
entire  circumference  of  the  bowel.  The  broadest  of  these  bands 
is  about  two  inches,  the  narrowest  about  eight  lines.  Over  the 
whole  of  these  spaces  is  the  mucous  membrane  completely  removed 


INTESTINAL  MUCOUS  MEMBRANE — CHRONIC  ULCERATION.  631 


by  the  ulcerative  process,  leaving  an  irregular  surface,  partly  gra- 
nulating, partly  ulcerated  in  the  mucous  tissue.  The  margins  are 
sharp,  clean,  and  accurately  cut,  almost  as  if  they  had  been  divided 
by  a knife,  and  slightly  turned  up,  so  as  to  leave  an  excavated  fur- 
row beneath  the  mucous  membrane  which  forms  the  margins.  The 
colour  of  the  bottom  of  these  ulcerated  patches,  when  recent,  was 
reddish  brown,  and  the  contiguous  mucous  membrane  was  red, 
verging  to  pale  rose  colour  and  peach  blossom.  This,  however, 
has  disappeared,  and  at  present  it  is  much  the  same  tint  as  the 
healthy  part  of  the  mucous  surface.  The  mucous  membrane  is  a 
good  deal  thickened  and  rather  firmer  than  in  the  sound  part  of  the 
tube.  At  each  of  these  ulcerated  bands  the  submucous  and  sub- 
serous  filamentous  tissue  is  thickened,  but  indurated  and  contract- 
ed, so  as  to  diminish  considerably  the  calibre  of  the  canal.  In  the 
first  patch,  which  is  about  twelve  inches  from  the  ileo-caecal  valve, 
this  thickening  consists  of  a firm  knot  like  a bean,  at  the  mesente- 
ric side  of  the  bowel,  and  the  intestine  is  contracted  to  about  half 
its  usual  capacity.  In  the  second,  about  five  inches  from  the  ileo- 
caecal  valve,  this  indurated  knot  at  the  mesenteric  attachment  of 
the  bowel  is  equally  well  marked,  and  has  had,  if  possible,  greater 
influence  in  contracting  and  diminishing  the  canal  of  the  bowel. 
The  ulcerated  surface  is  very  irregular  by  soft  spongy  eminences, 
separated  by  means  of  linear  furrows.  The  third  occupies  the  end 
of  the  ileum  and  beginning  of  the  colon,  and  has  entirely  destroy- 
ed, with  the  mucous  membrane  of  both  bowels,  the  ileo-caecal  valve. 
The  destroyed  part  here  presents  a surface  consisting  in  very  mi- 
nute round  granules ; and  in  the  beginning  of  the  colon  are  one 
or  two  large  irregular  granulations.  The  same  inflammatory  in- 
duration of  the  submucous  and  subserous  filamentous  tissue  has 
here  operated  in  diminishing  the  capacity  of  the  bowel ; and,  in- 
deed, previous  to  being  cut  open,  it  seemed  almost  impervious. 
The  inflammatory  process  here  had  produced  peritoneal  inflamma- 
tion, and  false  membrane  connecting  the  ileum^  caput  ccecum,  and 
part  of  the  colon  together.  The  vermiform  process  is  unaffected. 
Opposite  to  each  were  enlarged  mesenteric  glands,  and  especially 
at  the  last  mentioned  one  was  a cluster  of  large  knotty  masses. 

Though  I describe  the  ultimate  effects  of  this  destructive  pro- 
cess, I have  no  doubt,  from  what  I have  seen  of  other  cases  in  ear- 
lier stages,  that  it  is  the  result  of  chronic  inflammation  of  the  in- 
testinal mucous  membrane,  originating  in  the  agminated  follicles,  at 


632 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  lower  end  of  the  ileum,  and  from  them  spreading  to  the  adjoining 
mucous  membrane.  I had  an  opportunity  of  observing  the  pro- 
gress of  the  disease  for  more  than  two  years,  during  which  the  case 
was  more  or  less  under  my  care ; and  during  that  period  it  was 
possible  to  recognise  occasional  attacks  of  inflammation.  The  other 
symptoms  were  occasional  pain  of  the  belly,  never  severe,  unless  at 
the  period  of  the  above  attacks,  and  diarrhoea  alternating  with  con-  ' 
stipation,  afterwards  incessant  and  uncontrollable  diarrhoea,  wast- 
ing, and  hectic  fever ; — in  short,  all  the  symptoms  imputed  to  me- 
senteric decline ; (tabes  mesenterica.)  This  process,  therefore,  or 
chronic  inflammation  of  the  intestinal  mucous  follicles  and  mem- 
brane, with  or  without  ulceration,  I regard  as  one  of  the  patholo- 
gical causes  of  mesenteric  tabes.  The  enlargement  of  the  glands, 
in  which  this  disorder  has  been  very  generally  believed  since  the 
time  of  Wharton,  Baglivi,  and  Richard  Russell  to  consist,  is  mere- 
ly secondary,  and  is  a consecutive  effect  of  the  irritation  exercised 
at  the  organic  extremities  of  the  lymphatics  and  lacteals.  This 
view  of  the  relation  between  enlarged  mesenteric  glands  and  in- 
testinal inflammation,  though  already  stated  by  Broussais,  has  not, 
however,  been  established  by  that  author  on  authentic  proofs.  En- 
largement  of  these  glands  is  indeed,  I have  elsewhere  said,  a com- 
mon effect  of  irritation  at  the  organic  extremities  of  their  lympha- 
tics. 

§ 6.  Typhlitis,  Perityphlitis. — The  c(Bcum  or  blind  bowel  (typhlon 
enteron)  is  often  the  seat  of  a peculiar  disease,  which,  from  slow  and 
almost  imperceptible  commencements,  produces  so  much  havoc  as 
to  terminate  the  life  of  the  individual. 

This  disease  consists  in  inflammation  and  suppuration  of  the  cel- 
lular tissue  connecting  the  cacum  to  the  quadratus  lumborum  and 
other  parts,  or  in  inflammation  and  ulceration  of  the  mucous  mem- 
brane of  the  csecum,  and  often  of  the  vermiform  process,  and  which, 
advancing  by  very  gradual  and  insidious  steps,  destroys  the  mu- 
cous membrane,  aflPects  the  submucous  cellular  tissue  and  perito- 
neal coat,  and  either  causes  inflammation  of  the  latter  with  adhe- 
sion to  the  muscular  parietes  of  the  abdomen,  or  perforation  and 
fatal  peritonitis.  The  exact  mode  in  which  this  disease  commences 
is  not  always  perfectly  known.  But  from  the  dissection  of  those 
who  have  perished  by  it,  we  may  infer  that  the  following  descrip- 
tion makes  a near  approach  to  the  facts. 

At  first  the  glands  or  follicles  of  the  ccecum  become  enlarged 


intestinal  mucous  membrane — CJECAL  DISEASE.  633 


and  thickened  and  elevated  by  inflammation.  Then  the  summits 
of  these  covered  by  the  remains  of  purulent  matter  and  adherent 
mucus  are  separated ; and  below  are  disclosed  ulcerated  surfaces 
to  the  same  extent  as  the  glands  of  follicles  originally  aflfected. 
This  process  extends  and  deepens,  until  the  submucous  tissue  and 
the  peritoneum  are  affected.  Lymph  is  effused  over  the  surface 
of  the  latter  ; and  this  for  some  time  either  prevents  the  bowel 
from  being  perforated,  or  it  unites  the  peritoneal  coat  of  the  caecum 
with  the  muscular  peritoneum  and  the  abdominal  muscles.  At 
the  same  time  the  mucous  membrane  of  the  vermiform  process  is 
affected  by  inflammation  of  its  follicles  and  subsequent  ulceration  ; 
so  that  when  the  body  is  inspected  after  death,  this  appendage  pre- 
sents numerous  ulcers  along  its  internal  surface. 

When  the  inflammatory  action  has  caused  the  agglutination  of 
the  caecal  peritonaeum  to  the  muscular  peritonaeum  and  abdominal 
muscles,  the  morbid  process  is  not  thereby  stopped.  Very  com- 
monly it  is  extended  progressively  to  the  cellular  tissue  outside 
the  peritonaeum,  thence  to  the  muscles  in  the  right  iliac  region,  and 
it  may  even  produce  an  external  abscess  in  these  muscles,  the  open- 
ing of  which  on  the  surface  will  depend  on  the  time  during  which 
life  is  prolonged. 

In  one  case  of  this  kind,  which  I inspected  in  the  body  of  a young 
female  of  11  or  12,  the  caecum  itself  was  greatly  distended;  the 
extra-caecal  peritoneum  was  partly  adherent  to  the  muscular,  and 
partly  destroyed  by  ulceration  ; the  round  or  convex  part  of  the 
bowel  was  perforated  with  6 or  7 ragged  apertures,  various  in  size 
and  shape ; matter  was  found  all  round  it  and  between  them,  and 
also  externally  to  the  muscular  peritoneum,  and  between  the  fibres 
and  layers  of  the  abdominal  muscles ; and  the  skin,  though  not  de- 
stroyed, was  undermined.  When  the  disease  had  reached  this  point 
death  had  taken  place.  But  had  life  been  prolonged  a few  days 
more,  an  opening  in  the  skin  of  the  right  iliac  region  would  have 
taken  place  ; and  a fistulous,  cavernous  abscess  passing  through  the 
abdominal  muscles  and  into  the  cjecum  must  have  ensued.  In  this 
case  also  the  colon  was  small,  contracted,  and  almost  empty,  its 
size  being  more  like  that  of  the  ileum  than  the  colon,  while  the 
ileum  was  distended  by  feculent  contents  to  about  three  or  four 
times  its  usual  size,  and  presented  at  first  sight  the  appearance  of 
the  colon.  This  fact  deserves,  as  we  shall  see,  especial  attention. 

Another  mode  in  which  this  disease  shows  itself  is  the  following. 


634 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


After  the  disease  in  the  mucous  membrane  of  the  caecum  has  sub- ' 
sisted  for  some  time,  with  or  without  ulceration  of  the  caecum,  it  is 
followed  by  inflammation  taking  place  in  the  cellular  tissue  at  the 
posterior  part  of  the  caecum.  The  latter  bowel,  it  must  be  remem- 
bered, is  tied  down  and  fixed  by  cellular  tissue  to  the  right  iliac 
fossa  immediately  before  the  lumbar  and  iliacus  internus  muscles. 
The  inflammation  passes  to  this  cellular  tissue ; and  in  it  causes 
effusion  of  lymph  and  purulent  matter,  forming  a sort  of  abscess  I 
round  and  behind  the  caecum.  In  the  right  iliac  region  there  is 
then  recognized  a tumour  compressible  and  doughy,  and  giving  a ] 
sense  of  deep-seated  matter ; painful  when  pressed  at  certain  points,  J 
and  tending,  as  in  the  last  case,  to  advance  to  the  surface.  The 
disease  then  shows  itself  under  the  form  of  abscess  of  the  right  iliac 


In  this  state  after  matter  has  been  formed  one  of  two  results! 
may  take  place.  Either  the  inflammatory  action  continuing  andj 
the  suppurative  action  advancing,  a communication  by  ulceration^ 
may  be  opened  into  the  caecum,  and  through  this  the  matter  con-^ 
tained  in  the  tumour  passes  gradually  but  speedily  into  the  colon, 
and  is  thus  discharged  into  the  bowels.  Then,  if  adhesive  inflam- 
mation and  lymphy  deposit  take  place,  the  tumour  is  emptied  of  J 
its  contents  and  recovery  is  accomplished,  the  inflammation  and  J 
suppuration  being  confined  to  the  immediate  neighbourhood  andf 
attachments  of  the  caecum. 

Secondly,  it  may  happen  that  either  with  or  without  the  open-” 
ing  into  the  caecum  the  agglutinative  or  adhesive  inflammation  is:< 
imperfect  and  inert.  Lymph  is  not  effused  in  sufficient  quantity ' 
to  stop  the  spreading  of  the  suppuration.  Matter  is  effused  or  in- , 
filtrated  into  the  cellular  tissue  all  round  and  downwards  over  the  _ 
surface  of  the  iliacus  internus  muscle  ; and  after  great  ravages  arel 
committed,  it  appears  forming  an  outlet  at  the  margin  of  the  anus. 
This  is  an  unfavourable  result,  because  the  matter  in  advancing 
to  the  surface  is  attended  with  much  destruction  of  parts ; and  be- 
cause the  progressive  advancement  of  the  disease  denotes  a defi- 
ciency of  healthy  agglutinative  and  reparative  action. 

In  the  third  place,  the  suppurative  process  may  advance  to  the 
surface,  causing  superficial  abscess  in  the  right  iliac  region  and 
ulcerative  openings  to  discharge  the  purulent  contents  of  the  deep- 
seated  abscess.  This  appears  to  be  not  very  common  ; but  it  oc- 
curs in  a certain  number  of  cases.  It  is  not  very  favourable. 


INTESTINAL  MUCOUS  MEMBRANE — C^CAL  DISEASE.  635 


Although  I began  the  account  of  this  affection  by  representing 
it  to  originate  in  previous  disease  of  the  cacum  and  vermiform  ap- 
pendage, yet  there  occur  cases  in  which  the  latter  circumstance  is 
not  always  manifest.  If  the  first  movements  of  diseased  action  have 
taken  place  in  the  caecum,  it  has  been  externally ; and  hence  they 
have  advanced  to  affect  the  bowel  secondarily.  This  mode  of  pro- 
cedure may  best  be  illustrated  by  the  following  case. 

A young  female,  in  the  rank  and  occupation  of  a servant,  was 
sent  from  Leith  to  the  Royal  Infirmary  with  symptoms  believed  to 
indicate  the  presence  of  continued  fever.  The  skin  was  hot,  and 
though  not  dry,  was  imperfectly  transpiring ; the  tongue  was  co- 
vered with  a whitish  gray  pasty  fur ; there  was  some  thirst ; the 
expression  of  the  countenance  was  languid  and  feeble,  though  the 
face  was  flushed ; the  pulse  was  between  86  and  90,  rising  to  100  ; 
and  the  strength  was  impaired.  The  abdomen  was  a little  distend- 
ed and  slightly  painful ; yet  pressure  was  borne  tolerably  well. 
The  sound  emitted  was  clear  and  natural.  But  in  the  right  iliac 
region,  where  some  fidness  was  manifest,  the  sound  emitted  was 
dull ; and  considerable  pain  was  felt  on  pressing  or  handling  this 
region.  This  painful  sensation  also  extended  backwards  to  the 
loins ; but  was  more  complained  of  on  the  right  than  on  the  left 
side.  In  the  right  iliac  region  also,  but  most  towards  the  side  of 
the  region  and  its  posterior  aspect,  there  was  recognized  a more 
firm  and  resisting  yet  compressible  and  doughy  state  of  the  parts 
than  natural.  Pain  was  aggravated  by  coughing. 

Some  blood  was  drawn  from  the  arm ; twelve  leeches  were  ap- 
plied over  the  right  iliac  region ; and  laxative  medicine  was  given. 

Next  day  the  patient  said  she  felt  relieved  and  more  easy.  But 
the  state  of  parts  in  the  right  iliac  region  was  not  improved ; the  ab- 
domen was  rather  more  distended,  with  some  tympanitic  resonance ; 
the  pulse  was  above  100,  not  full  but  hard  ; the  skin  was  dry;  the 
urine  scanty  and  sedimentous ; and  the  bowels  had  been  moved 
scantily  and  imperfectly : the  fur  on  the  tongue  was  much  as  before. 

Twelve  leeches  were  ordered  on  the  right  iliac  region,  to  be  fol- 
lowed by  warm  fomentations  and  a poultice ; and  an  enema  was 
directed  to  be  administered. 

Next  morning  the  patient  became  suddenly  very  feeble  and 
died. 

Inspection  disclosed  the  following  appearances. 

A portion  of  bowel  between  3^  and  4 feet  long,  which  turned 
out  to  be  the  lower  part  of  the  ileum,  was  greatly  distended  chiefly 


636 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


witli  air  ; of  a dark  brown-red  colour,  and  with  its  peritoneal  coat  j 
covered  and  penetrated  by  an  infinite  number  of  red  vessels.  This  ; 
piece  of  intestine  formed  in  this  state  several  turns  or  convolutions ; 
and  a considerable  portion  of  it  had  been  pushed  over  to  the  right 
side.  The  ileum  above  this  was  distended  but  less  reddened. 
W hen  cut  open  the  contents  were  much  as  usual,  but  with  more 
air.  The  mucous  membrane  was  greatly  reddened,  friable,  rough, 
and  easily  detached.  The  substance  of  the  bowel  was  vascular  and 
reddened.  But  of  the  follicles  there  was  neither  elevation  nor  ul-' 
ceration.  The  ileo-csecal  valve  was  reddened.  The  interior  of , 
the  caecum  was  also  reddened  and  softened  ; but  no  ulceration  3 
had  taken  place.  The  appendix  vermiformis  presented  a few 
enlarged  follicles  along  its  interior.  The  ascending  arch  of  the 
colon  was  comparatively  empty ; and  the  rest  of  the  bowel  was 
pretty  natural,  and  void  of  any  thing  except  thin  feculent  matter 
and  mucus.  The  mucous  membrane  of  the  colon  was  not  unna-^ 
tural. 

External  to  the  caecum,  on  the  lateral  and  posterior  aspects  of  ^ 
that  bowel,  were  deposits  of  purulent  matter  and  loose  lymph,  ex- 
tending upwards  and  backwards  for  a good  space.  This  purulent  .1 
matter  occupied  the  place  of  the  perityphlic  cellular  tissue ; was 
not  contained  within  a distinct  or  well-formed  cyst,  but  appeared 
to  be  loosely  infiltrated  into  the  space  around  the  caecum.  No 
perforation  of  the  caecum  had  taken  place.  But  all  round  the 
cellular  tissue  was  reddened,  softened,  loaded  with  bloody  serum 
and  specks  of  purulent  matter  ; and  the  parts  wmre  ash-coloured 
and  offensive  smelling,  as  if  proceeding  to  mortification. 

In  this  case  the  cause  of  death  was  twofold.  First,  the  general 
inflammation  of  the  lower  portion  of  the  ileum  {enteritis  ; ileitis)^ 
caused  apparently  by  obstruction  and  distension  of  the  whole  bowel, 
in  consequence  of  the  pressure  created  by  the  inflammatory  abscess 
round  the  caecum  ; and  secondly,  this  suppurative  inflammation  of 
the  perityphlic  cellular  tissue  itself,  which,  though  operating  chiefly 
as  a cause  of  pressure  on  the  caecum  and  obstruction  to  the  peristal- 
tic motion  of  the  bowel,  yet  did  further  mischief  by  the  peculiar 
effects  of  a bad  suppuration  on  the  system  at  large. 

In  this  case  also,  there  is  every  reason  to  believe  that  the  pri- 
mary morbid  action  was  seated  in  the  perityphlic  cellular  tissue ; 
and  that  the  inflammation  and  suppuration  there  established  had 
acted  on  the  caecum  by  compressing  it,  and  thus  obstructing  the 
descent  of  the  contents  of  the  ileum,  had  caused  over-distension  of 


INTESTINAL  MUCOUS  MEMBRANE C^CAL  DISEASE.  637 


the  latter  and  general  inflammation  much  as  a strangulated  hernia. 
Indeed,  the  appearance  of  the  ileum  was  quite  similar  to  that  pre- 
sented by  intestines  above  a point  of  strangulated  bowel. 

The  termination  of  this  disease  is,  nevertheless,  not  necessarily  or 
inevitably  fatal.  If  the  tumor  in  the  right  iliac  region  be  recog- 
nized before  suppuration  has  taken  place,  resolution  may  be  accom- 
plished under  the  use  of  local  and  general  blood-letting,  with  very 
gentle  aperients.  Several  patients  in  this  state  I have  treated  and 
seen  get  perfectly  well;  and  there  is  always  more  chance  of  com- 
plete recovery  if  the  treatment  be  commenced  in  this  stage,  than  if 
it  be  delayed  until  suppuration  has  occurred.  After  this  event  the 
favourable  termination,  though  less  likely,  may  be  effected  in  the 
mode  already  mentioned. 

Though  all  the  causes  of  this  disorder  may  not  be  perfectly 
understood,  yet  several  are  sufficiently  obvious  and  intelligible.  In 
the  first  place,  the  peculiar  situation  and  fixed  attachment  of  the 
ccecuin  must  be  regarded  as  an  important  disposing  cause.  That 
bowel  being  attached  by  its  whole  posterior  surface,  by  means  of 
filamentous  tissue,  to  the  muscles  of  the  right  lumbar  region,  and 
with  its  blind  sac  or  receptacle  below  the  level  of  the  ileo-cascal 
aperture,  and  in  a dependent  position,  is  liable  to  become  distended 
with  excrementitial  matter,  which  the  bowel  itself  cannot  easily  ex- 
pel and  raise  against  gravity.  Then  the  vermiform  process  itself, 
by  its  dependent  position,  may  encounter  difficulty  in  evacuating 
its  contents. 

Secondly,  all  articles  taken  with  food,  or  otherwise  swallowed 
and  not  easily  carried  along  the  bowels,  are  here,  from  the  position 
of  the  ccBcum,  more  readily  detained.  The  stones  of  the  drupaceous 
fruits,  seeds,  pieces  of  money  or  metal,  fragments  of  bones,  marbles, 
and  similar  substances,  are  liable  to  be  here  stopped,  and  by  their 
presence  to  cause  irritation.  In  fatal  cases  the  caecum  sometimes 
contains  hardened  feces,  concretions ; and  in  one  case  I found  frag- 
ments of  glass. 

Kaltschmidt  records  the  case  of  an  artisan  of  25,  who,  about  one 
month  after  swallowing  many  walnuts  and  medlars,  was  attacked 
with  symptoms  of  ileus,  which,  after  lasting  for  15  days,  terminated 
in  death.  On  inspecting  the  body  Kaltschmidt  found  the  whole 
tract  of  the  bowels  presenting  marks  of  inflammation,  and  the  ileum 
at  its  lower  end  near  the  valve  of  Bauhin  perforated  in  three  parts, 
and  contorted  or  twisted  so  as  to  form  three  separate  cavities  filled 
with  indurated  feculent  matter.  The  destruction  was  so  complete 


638 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


that  the  ileum  seemed  detached  from  the  ccecum,  and  adhered  by  aj 
few  shreds  only.  Feculent  matter  had  escaped  into  the  abdominal j 
cavity  near  the  lacerated  portion  of  ileum  ; and  in  this  was  found] 
about  half  an  ounce  of  the  stones  of  the  medlars  eaten,  and  about] 
as  much  in  the  faeces  within  the  ileum.* 

Similar  instances  of  the  stoppage  of  stones  of  the  drupaceous  fruits, 
bones,  pieces  of  money,  and  similar  foreign  bodies,  are  recorded  by  ‘ 
Younge,  Amyand,  Fielding,  Stoll,  and  other  authors.  In  certain 
instances  intestinal  concretions  are  formed  either  spontaneously  or 
around  bodies  of  the  kind  now  mentioned.  In  either  case  the  stop- 
page of  such  bodies  in  the  cceeum  is  at  once  probable,  and  likely 
to  produce  irritation  and  inflammation  of  that  portion  of  the  intes- 
tinal tube. 

These  must  be  regarded  as  disposing  causes. 

As  to  age,  it  seems  to  take  place  most  frequently  in  persons  be-i 
tween  20  and  30. 

As  to  sex,  MM.  Husson  and  Dance  say  that  it  is  more  frequently! 
seen  in  males  than  in  females.!  My  own  experience,  nevertheless, '1 
leads  to  the  opposite  conclusion.  I have  seen  the  disease  in  a greater, 
number  of  females  than  males ; I have  found  it  more  unmanage- ’ 
able  in  females  than  in  males  ; 1 have  never  seen  a fatal  case  in  a 
man,  but  several  in  females.  I infer  that  the  class  of  females  in] 
whom  it  is  most  frequent  is  that  of  domestic  servants  and  seam- 
stresses. 

As  to  the  influence  of  articles  of  food,  it  has  been  said  that  the  j 
use  of  oatmeal,  which  favours  the  formation  of  intestinal  concretions,] 
is  also  liable  to  be  followed  by  this  disease.  Yet  it  does  not  appear^ 
that  the  disease  is  less  frequent  in  France  and  England,  where  .j 
wheaten  bread  is  used,  than  in  Scotland,  where  oatmeal  is  used  as 
part  of  food.  It  appears  to  me  also  very  questionable,  whether 
among  those  who  in  Scotland  use  oatmeal  much  as  food,  it  is  more 
frequent  than  among  those  who  use  it  little  or  not  at  all. 

Constipation  is  probably  favourable  to  its  formation  ; and  what- 
ever tends  to  impede  or  interrupt  the  periodical  evacuation  of  the 
bowels  must  tend  to  produce  this  as  it  does  other  disorders.^ 


■*  Caroli  Fred  Kaltschmidt  de  ileo  a scrupulis  Pyrorum  Mespilaceorum  eroso  per-  ^ 
forato.  dense,  Imo  Oct.  1747.  Haller,  Disput.  Medico-Pract.  iii.  p.  510. 

•f-  Memoire  sur  quelques  engorgemens  inflammatoires  qui  se  development  dans  la 
fosse  iliaque  Droite.  Repertoire  d’Anatomie,  &c.  T.  iv.  p.  74.  Paris,  1827. 

$ Ferrall  in  Edin.  Med.  and  Surg.  Journal,  Vol.  xxxvi.  p.  1.  Edin.  18.31.  And 
Dr  Burne  in  Medico-Chirurgical  Transact,  xx.  p.  200,  and  xxii.  ^ 


INTESTINAL  MUCOUS  MEMBRANE — DYSENTERY. 


639 


§ 7.  Colonia.  Dysentery.  Colonitis. — The  opinion  that  dysen- 

tery depends  on  inflammation  of  the  howels  is  very  ancient ; hut 
the  authority  of  Cullen  succeeded  for  a time  in  throwing  doubt  and 
obscurity  on  a doctrine,  in  favour  of  which  various  positive  and  un- 
equivocal facts  have  since  been  collected.  The  state  of  the  intes- 
tines in  this  disease  has  been  described  by  Pringle,  Baker,  Donald 
Monro,  Hunter,  and  Baillie,  Cheyne,  and  O’Brien  ; and  their  ac- 
counts, with  some  trifling  exceptions,  in  general  correspond.  In 
four  dissections  made  by  Pringle  in  the  Flanders  campaign  of  1744, 
the  villous  coat  of  the  colon  was  red  or  vascular,  and  abraded  or 
ulcerated ; the  lower  end  of  the  colon,  and  generally  the  rectum., 
was  in  a state  termed  mortification  ; the  ligamentous  bands  are 
said  to  be  relaxed,  half  corrupted,  or  entirely  obliterated;  and  the 
colon,  sometimes  the  ileum  and  stomach,  much  distended  by  air.* * * § 
In  the  inspections  recorded  by  Baker  of  the  London  epidemic  of 
1762,  the  villous  membrane  of  the  rectum,  colon,  caecum,  and 
occasionally  part  of  the  ileum,  was  more  or  less  reddened,  vel-' 
vety-granular,  and  occupied  by  numerous  minute  bodies  like 
small-pox  pustules,  but  harder  and  solid  when  divided,  and  fun- 
gous eminences.  These  hard  pustules  and  fungous  eminences 
were  manifestly  seated  in  the  Lqlated  follicles.  In  one  case  four 
or  five  perforations  had  taken  place  in  the  transverse  arch  of  the 
colon.f  In  persons  cut  off  by  old  dysentery,  Monro  repre- 
sents the  villous  membrane  of  the  rectum  and  colon  as  inflam- 
ed, with  livid  spots  in  the  arch  of  the  latter ; and  in  one  seized 
by  violent  pains  of  the  bowels  two  days  before  death  the  ileum 
was  reddened.^  From  a subsequent  account  by  the  same  author, 
it  appears  that  the  colic  mucous  membrane  as  high  as  the  valve, 
was  occupied  by  livid  or  black  spots  of  various  size,  occasioned  by 
black  blood  in  the  submucous  filamentous  tissue ; and  that  in  the 
centre  of  each  spot  there  was  more  or  less  erosion  of  the  viUous 
membrane.  Though  no  black  spots  or  erosions  were  seen  in  the 
mucous  membrane  of  the  ileum,  in  one  or  two  minute  red  spots, 
and  slight  traces  of  inflammation  were  recognized.§  The  general 
accuracy  of  these  statements  is  briefly  confirmed  by  F.  L.  Bang  in 

* Observations  on  the  Diseases  of  the  Army,  by  Sir  John  Pringle,  AI.  D.  London, 
1768.  Chap.  6. 

-f-  De  Catarrho  et  de  Dysenteria  Londinensi  epidemicis  utrisque,  anno  1762,  Libellus. 
Auct.  G.  Baker,  CoU.  R.  &c.  Lond.  1764. 

An  account  of  the  Diseases,  &c.  By  Donald  Monro,  M.  D.  Lond.  1764. 

§ Essays  and  Observations,  Physical  and  Literary,  Vol.  iii.  article  25. 


640 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  following  terms.  ‘‘  Perlustrata  interna  facie  intestini  cseci 
atque  coli,  vidimus  tunicam  villosam  alibi  adhserentem,  et  alibi 
derasam,  ibidemque  tunicam  vasculosam  lividara  quasi  sanguine 
plenam,  niesenterium  rubescens  vasis  distinctis  plenissimum.”* 

Dr  John  Hunter,  on  the  contrary,  who  states  that  he  never  saw 
abrasion  or  mortification  of  the  villous  coat,  is  inclined  to  think, 
that  in  the  dissections  mentioned  by  Pringle,  the  black  colour  aris- 
ing from  extravasated  blood  was  mistaken  for  gangrene.  Though 
it  is  impossible  to  doubt  that  this  mistake  has  been  often  committed 
in  describing  the  necroscopic  changes  of  the  gastro-enteric  mem- 
brane, it  must  not  be  forgotten  that  inflammation  occasionally  ter- 
minates in  mortification,  and  that  instances  of  this  are  not  unusual 
in  the  tropical  form  of  the  disease  especially.  The  general  fact  of 
inflammation  is  further  confirmed  by  Maximilian  Stoll,  who  de- 
scribes the  caecum,  colon,  especially  its  transverse  arch,  and  rec- 
tum, in  persons  cut  off  by  acute  dysentery,  as  swelled,  thickened, 
hard,  and  fleshy,  of  a leaden  or  dull  red  colour,  the  mucous  mem- 
brane of  a foul  or  dingy  red  tint  with  blood,  or  of  a deep  rank 
green  tinge  removable  neither  by  water  nor  the  sponge, — an  ap- 
pearance indicating  the  commencement  of  elementary  decompo- 
sition, f 

Occasionally  dysentery  prevails  during  summer  and  autumn  in 
this  country;  and  both  in  previous  seasons  and  in  the  summer  of 
1 843,  we  had  opportunities  of  observing  its  eflFects  on  the  intestinal 
coats.  In  several  cases  which  I examined,  the  following  were  the 
appearances. 

The  whole  tract  of  the  colon  was  thick,  massive,  and  heavy,  to- 
tally different  from  the  usual  membranous  appearance  of  that  bowel. 
This  thickness  was  partly  in  the  mucous  membrane  and  partly  in 
the  submucous  cellular  tissue.  The  mucous  membrane  was  thick, 
of  a reddish  colour,  firm,  and  more  solid  than  in  the  normal  state, 
which  was  shown  by  the  peculiar  mode  in  which  it  was  cut.  Its 
surface  was  covered  with  much,  viscid,  thick^^ergntjnucus,  which 
was  indeed  partly  albuminous.  The  section  showed  that  it  was 
thickened,  apparently  from  effusion  of  lymph  into  its  interstitial 
tissue,  or  from  the  great  congestion  of  the  vessels ; the  colour  was 
also  of  a deeper  fawn  red  here  than  natural.  The  calibre  of  the 
bowel  was  much  contracted,  the  size  and  capacity  of  the  colon  being 
not  so  large  as  that  of  the  ileum. 

* Selecta  Diarii  Nosocomii  Hafhiensis,  Tom.  ii.  178fi.  P.  223. 

t Ratio  Mtdendi,  Partis  iii.  Vol.  iii.  Sectionis  4. 


COLIC  MUCOUS  MEMBRANE — DYSENTERY. 


641 


When  the  mucous  membrane  was  cleared  of  adherent  mucus, 
numerous  patches,  variable  in  size  from  that  of  a pea  to  that  of  a 
sixpenny  piece,  or  even  larger,  and  irregular  in  figure,  appeared 
covered  with  a coating  of  albuminous  mucus  tinged  with  the  co- 
louring matter  of  the  bile  and  excrement.  When  these  coverings 
were  removed,  they  disclosed  surfaces  destroyed  by  irregular  ul- 
ceration of  tbe  mucous  membrane. 

These  ulcers  had  originated  in  the  follicles  of  the  colon,  which 
had  become  softened  at  the  commencement  of  the  attack,  and  had 
then  proceeded  to  sloughing  and  ulceration.  The  state  now  de- 
scribed extended  along  tbe  whole  colon,  but  was  most  remarkable 
in  the  transverse  arch  and  sigmoid  flexure. 

In  some  other  cases  the  disease  was  confined  to  the  lower  part 
of  the  sigmoid  flexure  and  to  the  rectum.  The  mucous  membrane 
had  become  thickened,  and  similar  patches  of  ulceration,  very  ir- 
regular in  shape,  had  been  formed,  covered  in  like  manner  by 
lymph  tinged  with  the  colouring  matter  of  the  bile  and  excrement. 
The  coats  of  the  bowel  were  in  like  manner  thickened  and  indu- 
rated, and  the  area  of  the  bowel  was  contracted. 

The  necroscopic  appearances  of  tropical  dysentery  have  been 
described  more  or  less  fully  by  Sir  W.  Farquhar,  Sir  George 
Ballingall,  Mr  Bampfield,  Mr  Annesley,  whose  several  testimonies 
tend  to  establish  the  general  conclusion,  that  this  disease  consists 
in  inflammation  of  the  colic  mucous  membrane,  spreading  in  gene- 
ral, not  always  or  necessarily,  with  ulceration,  but  advancing  to  this 
process  when  not  suitably  or  promptly  opposed,  and  occasionally 
ending  in  death  of  portions  of  the  mucous  membrane.  Of  this  in- 
flammation the  peculiarities  are,  1*’?,  that  it  is  confined  with  consi- 
derable accuracy  to  the  colon  or  large  intestine,  and  the  ileum  be- 
ing but  rarely  affected,  and  only  at  its  lower  or  colic  extremity ; 
2rf,  that  this  inflammatory  action  spreads  continuously  from  the  ileo- 
coecal  valve  along  the  mucous  membrane  of  the  ccecum^  right  branch 
of  the  colon,  transverse  arch  and  sigmoid  flexure,  at  various  rates, 
and  with  various  effects,  but  at  all  times  with  that  of  producing  fre- 
quent copious  discharges  of  mucous,  muco-purulent,  and  blood-co- 
loured stools;  3rf,  that  this  process  may  continue  for  some  time 
without  producing  ulceration  of  the  mucous  corion,  or  inflamma- 
tion of  the  submucous  tissue ; that  these  phenomena  may  take 
place,  nevertheless,  in  certain  circumstances,  at  an  early  period ; 
and  that  in  others  they  occur  towards  the  conclusion  of  the  disease ; 

ss 


G42 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


and  4^/<,  that  though  this  inflammatory  process  in  general  com- 
mences with  disorder  of  the  circulation,  and  increased  number  of 
the  cardiac  pulse,  it  may  commence  without  this,  and  almost  always 
goes  on  when  once  established,  without  the  pulse  being  much  quick- 
ened, till  the  inflammatory  process  either  affects  the  submucous 
tissue,  or,  which  is  nearly  the  same  thing,  begins  to  effect  mortifi- 
cation of  the  mucous  tissue. 

The  formation  of  numerous  ulcers  in  the  tract  of  the  colon  may 
be  said  to  indicate  the  chronic  form  of  the  disorder.  This,  from 
the  statements  of  Ballingall,  Bampfield,  and  Annesley,  appears  to 
be  more  common  in  the  tropical  variety  of  the  disorder  than  in  that 
observed  in  more  temperate  climates.  The  same  change,  however, 
was  seen  by  Morgagni,  Lieutaud,  Baillie,  Cooke,  and  others,  in  the 
dysenteric  affections  of  the  latter  description.  In  one  instance  of  a 
man  of  65,  who  had  for  several  weeks  laboured  under  chronic 
purging,  and  whose  body  I inspected  for  my  friend  Mr  Caird,  I 
found  the  colic  mucous  membrane  occupied  by  numerous  ulcers, 
irregular  in  shape,  and  varying  in  size  from  the  area  of  a split  pea 
to  that  of  a sixpence,  and  even  of  a shilling.  The  lower  end  of 
the  ileum  presented  a few  small  patches  of  ulceration  scarcely  pe- 
netrating the  mucous  corion.  In  the  caecum,  on  the  other  hand, 
they  were  deeper,  and  had  not  only  penetrated  this  membrane,  but 
were  destroying  the  submucous  tissue.  In  the  ascending  portion 
and  transverse  arch  they  had  effected  equal  destruction,  and  in  one 
or  two  the  peritonjeixm  only  was  left.  The  bottom  or  surface  of 
these  ulcers  varied  according  to  the  stage  of  destruction.  In  the 
least  advanced,  in  which  the  mucous  tissue  was  not  entirely  de- 
stroyed, the  surface  of  the  ulcer  was  a sort  of  pale-red  or  gray- 
brown  colour.  When  the  surface  was  formed  by  exposed  submu- 
cous tissue  it  was  more  ashen-coloured,  but  with  red  streaks  de- 
pending on  blood-vessels.  The  muscular  layer  gave  it  a red  or 
brown  tint ; and  where  the  peritonaeum  was  exposed,  it  was  thick- 
ened, reddened,  and  in  general  coated  by  a layer  of  lymph  on  its 
free  surface.  The  edges  of  these  ulcers,  if  formed  of  mucous  tis- 
sue, were  generally  well-marked,  sometimes  thickened,  and  occa- 
sionally slightly  turned  upwards  from  destruction  of  the  submucous 
filamentous  layer.  Selaom  were  they  red ; and  their  most  prevail- 
ing tint  was  light  or  ash-coloured  brown.  The  colic  mucous  mem- 
brane was  generally  traversed  by  blood-vessels  at  variable  distances 
from  each  other.  The  villi  w'ere  obliterated  and  indistinct.  The 


COLIC  MUCOUS  MEMBRANE — DYSENTERY. 


643 


valvular  folds  also  were  destroyed,  and  the  cellular  arrangement 
of  the  bowel  could  no  longer  be  recog-nized. 

It  is  not  unimportant  to  know  that  these  ulcers  of  the  intestinal 
mucous  membrane  may,  under  certain  circumstances,  undergo  a 
process  of  reparation.  The  steps  of  this  process,  which  was  origi- 
nally observed  by  Dr  Donald  Monro,  have  been  well  described  by 
Petit  and  Serres  in  their  account  of  the  entero-mesenteric  disease 
of  Paris,  and  by  Dr  Latham  in  that  of  the  epidemic  of  INIillbank 
Penitentiary.  From  the  observations  of  these  authors  it  results, 
that  the  first  step  towards  repair  consists  in  the  loose  margin  of  ul- 
cerated mucous  membrane  becoming  fastened  down  to  the  muscu- 
lar layer  or  the  peritoneal  coat  respectively,  by  deposition  of  lymph 
all  round.  This  lymphy  deposition  forms  an  elevated  prominent 
ring,  inclosing  a depressed  space  corresponding  to  the  centre  of  the 
sore,  and  which  about  the  same  time  acquires  a reticular  appearance 
from  intersecting  filaments  of  lymph,  among  which  may  be  seen 
minute  red  vessels.  As  the  process  advances,  these  filaments,  by 
acquiring  solidity  and  strength,  seem  to  draw  the  mucous  membrane 
forming  the  edges  to  the  centre  of  the  ulcer,  while  the  elevated 
ring  becomes  flattened.  At  length,  the  lymphy  deposition  being 
covered  by  a thin  pelhcle  newly  formed  completes  the  cicatrix. 
When  the  ulcerated  spots  are  examined  in  this  state,  the  ragged 
edges  of  mucous  membrane  are  found  to  be  mutually  approximated ; 
and  the  peritonaeum  at  the  same  time  to  be  puckered  or  drawn  to- 
gether, appearing  as  if  a small  portion  of  the  intestine  had  been  taken 
by  the  forceps  and  tied  by  a ligature.  This  shows  that  the  process 
of  repair  consists  not  in  the  mucous  corion  being  reproduced,  but 
in  the  opposite  margins  of  its  breach  making  as  it  were  an  effort  to 
approach  by  means  of  the  lymphy  exudation  from  the  peritonaeum, 
which  was  thus  necessarily  contracted. 

§ 8.  Pustuh-tubercular  eminences.  Probable  Tubercular  depo- 
sit in  the  isolated  Follicles. — I am  not  aware  that  the  circum- 
stances on  which  the  formation  of  hard  pustules  or  tubercles  of 
the  colic  mucous  membrane  depends,  have  been  investigated  or 
determined.  Is  this  membrane  bable  to  a peculiar  pustular  or 
pustulo-tubercular  inflam.mation  ? That  they  do  not  occur  in  all 
forms  of  colic  inflammation  is  proved  by  the  fact,  that  they  were 
not  seen  in  the  camp  dysentery  of  1743,  and  but  rarely  in  the  tro- 
pical dysentery  of  the  east,  while  they  were  observed  in  every  case 
of  the  London  dysentery.  Dr  John  Hunter,  who  saw  them  in  all 


644 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  dysenteric  inspections  which  he  performed  in  Jamaica,  describes  : 
them  as  true  pustules^  though  they  contain  no  purulent  matter, 
and  represents  them  as  seated  beneath  the  villous  coat  or  in  the  sub-  ij 

mucous  tissue.  Each  pustule,  though  at  first  small,  round,  and  ! 

reddish,  not  more  than  the  one-tenth  of  an  inch  in  diameter,  gra-  |i 

dually  enlarges  till  it  attains  the  diameter  of  one-fourth  of  an  inch,  j 

becoming  at  the  same  time  paler.  In  this  stage  a minute  crack  or  ' 

fissure  appears  at  the  top,  and  gradually  enlarges,  when  the  con-  ' 

tents  of  the  pustule  are  found  to  be  cheese-like  substance.  As  the  j 

opening  enlarges,  the  edges  become  prominent,  the  base  grows 
rough,  and  matter  sometimes  tinged  with  blood  oozes  from  it. 

This  is  the  progress  of  one  pustule  or  tubercle ; but  they  are  ge- 
nerally in  clusters,  and  may  coalesce  and  form  an  unequal  ulcer-  ]■ 
ated  surface  with  a hard  thickened  base.*  9 

It  is  impossible  to  doubt  that  these  pustulo-tubercular  bodies  are  9 
the  isolated  follicles  either  in  a state  of  chronic  inflammation  and  SI 
enlargement,  or  infiltrated  with  tubercular  matter,  or  degenerated  91 
in  consequence  of  the  long  continuance  of  chronic  inflammation.  9 
In  general  there  are  three  forms  under  which  this  state  presents  3 
itself.  One  is  when  the  subfollicular  cellular  tissue  becomes  thick-  9 
ened,  enlarged,  and  indurated.  Another  is  when  this  tissue  is  infil-  9 
trated  with  tubercular  matter.  This  takes  place  in  dysentery  in  9 ■ 
those  of  strumous  habit,  and  in  the  phthisical.  A third  is  when  the  X 
follicular  membrane  is  degenerated  and  converted  into  a hard  warty  9 ■ 
sort  of  matter,  which  usually  splits  or  is  fissured  on  the  apex.  In  9 ■ 
either  of  these  three  cases  the  follicles  are  prone  to  undergo  a spe-  ^ 
cies  of  bad  and  almost  insanable  ulceration,  causing  chronic  diar-  9 
rhoea  with  great  weakness  and  wasting.  9[ 

Of  much  the  same  nature  are  the  granulations  of  the  intestinal  w 
mucous  membrane,  described  in  the  persons  of  the  phthisical  by  M 
Louis.  According  to  this  observer,  these  granulations  are  of  two  9 
sorts,  the  semicartilaginous  and  the  tubercular.  The  former,  which  9 
in  the  cases  inspected  were  most  frequent  and  most  numerous,  were 
distributed  equally  round  the  bowel  ; and  though  dispersed  occa-  f 
sionally  through  its  whole  length  with  intervals  of  two  or  three  I 
square  inches,  they  were  generally  largest  and  most  numerous  to- 
wards the  caecum.  They  were  not  seen  in  the  colon.  Generally 
after  attaining  the  size  of  a pea,  the  mucous  membrane  at  top  be- 

* Observations  on  the  Diseases  of  the  Army  in  Jamaica,  (Stc.  By  John  Hunter, 

M.  D.,  F.  R.  S.,  &c.  Lond.  1784.  Chap.  4,  Sect.  2,  p.  230,  231. 


INTESTINAL  MUCOUS  MEMBRANE—  INDURATION. 


645 


came  thick,  soft,  and  gave  way;  and  the  destructive  process  thus 
begun  advanced,  forming  an  ulcer  with  hard,  white,  opaque  edges. 
The  tubercular  granulations,  which  were  less  frequent,  were  never 
seen  near  the  duodenum,  and,  always  most  numerous  near  the 
coecum,  occupied  indiscriminately  any  point  of  the  bowel.  They 
terminated  by  softening  in  minute  ulcers.  It  does  not  appear  that 
the  ulcers  thus  formed  are  ever  cicatrized.* 

When  cicatrization  either  of  the  simple  or  the  tubercular  ulcer 
does  not  take  place,  or  takes  place  imperfectly,  yet  without  causing 
immediate  death,  it  gives  rise  to  the  symptoms  denominated  lientery 
(Xs/si/rsf/a,  slippery  bowels) ; and  its  natural  termination  is  dropsy, 
abdominal  and  general. 

By  these  ulcers  the  colon  is  occasionally  perforated  with  the 
same  effects  as  other  parts  of  the  canal.  Haller  records  an  instance 
in  which  an  ulcer  of  the  transverse  arch,  by  gradual  absorption, 
perforated  the  coats  of  the  stomach  ;f  and  Lowdell  mentions  one 
in  which  an  ulcer  of  the  sigmoid  flexure  effected  an  opening  into 
the  urinary  bl  adder.  J 

§ 9.  Infiammatory  induration.  Shleroma. — Another  effect  of  in* 
flammation  common  to  the  gastro-enteric  mucous  membrane  with 
others  is  more  or  less  permanent  thickening  of  its  substance,  or  that 
of  the  submucous  tissue,  inducing  contraction  of  the  capacity  of  the 
canal.  This  takes  place  in  the  oesophagus,  in  the  cystic  and  common 
bile  duc^s,  and  in  the  intestines,  small  and  great.  In  the  oesopha- 
gus it  constitutes  one  of  the  most  manageable  forms  of  stricture  of 
that  tube,  in  so  far  as  the  swelling,  under  proper  management,  occa- 
sionally disappears.  (Grashuis,  Bleuland,  Monro,  Howship.)  Its 
most  usual  seat  is  in  the  neighbourhood  of  the  cricoid  cartilage,  and 
occasionally  at  the  cardia.  A good  example  of  the  former  is  de- 
lineated by  Dr  Armstrong.  In  the  common  biliary  duct  I have 
seen  this  inflammatory  thickening  give  rise  to  jaundice ; and  I sus- 
pect this,  and  not  spasm  of  the  tube,  is  the  most  frequent  cause  of 
biliary  obstruction.  In  the  ileum  this  contraction  is  perhaps  less 
frequent  than  in  the  colon.  Yet  in  the  case  above-mentioned  the 
diameter  of  the  bowel  was  very  much  diminished,  chiefly  by  inflam- 
mation of  the  submucous  and  subserous  filamentous  tissue ; and  Dr 
Charles  Combe  records  an  interesting  example  of  thickening  of  the 
lower  end  of  the  ileum,  in  which  the  capacity  of  the  bowel  was  di- 

* Recherches  Anatomico-Pathologiques  sur  la  Phthisie.  Paris,  1825. 

-}■  Opuscula  Patholog. 

t Mem.  Med.  Society. 


646 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


minished  to  the  size  of  a turkey’s  quill.*  In  the  colon  this  inflam- 
matory induration  is  more  frequent.  It  takes  place  chiefly  in  the 
sigmoid  flexure,  and  in  the  connection  with  the  rectum.  Of  the 
former  instances  are  recorded  by  Haase,  Christian  Wincker,  Lau- 
bius,  Portal,  and  Baillie,  and  delineated  by  Mr  Annesley ; and  in- 
deed it  is  no  uncommon  consequence  of  tropical  dysentery.  Of  its 
occurrence  in  the  latter  situation,  Willan  records  an  excellent  ex- 
ample ; and  I may  add,  that  I have  seen  several  cases  of  it  in  per- 
sons who  have  returned  to  this  country  after  severe  or  long-conti- 
nued dysentery. 

§ 10.  Membranous  Exfoliation. — In  some  rare  instances  more  or 
less  of  the  intestinal  mucous  membrane  has  become  completely  dead, 
and  been  discharged  like  a foreign  body.  Of  this  mode  of  exfoliation 
of  the  mucous  membrane  of  the  ileum,  occasionally  with  the  muscular 
and  peritoneal  tunics,  good  examples  are  recorded  by  Monro  second 
from  Cullen,t  Mr  William  Dougall,J  Dr  T.  Sanden,§  and  Mr  John 
Bower.  11  Dr  Baillie  records  a case  in  which  a large  portion  of  the 
colic  membrane  was  voided  and  Mr  J.  M.  Bowman  mentions  one 
in  which  a portion  of  the  colon  and  cmcum  with  attached  mesocolon 
are  said  to  have  been  discharged.**  This  subject  has  been  most  fully 
examined  by  Dr  William  Thomson  ; and  to  his  Memoir  I refer  the 
reader,  tf 

An  effect  of  inflammation  of  the  gastro-enteric  membrane,  as 
well  as  the  tracheo-bronchial,  is  albuminous  or  sero-albuminous 
exudation.  This  was  observed  by  M.  Bretonneau  in  the  oesopha- 
gus; by  Baillie,  Andral,  Howship,  Godman,  and  Villerme  in  the 
stomach;  and  by  a considerable  number  of  authors,  in  the  colon. 
In  all  cases  the  formation  of  these  membranous  substances  has  been 
preceded  and  accompanied  by  marks  of  inflammatory  action.  In 
the  cases  of  M.  Bretonneau  they  were  connected  with  tracheal  and 
oesophageal  inflammation.  ||  In  that  of  Howship  it  was  the  con- 
sequence of  swallowing  boiling  water  ;§§  in  the  cases  of  Andral 

^ Transact.  Coll.  Phys.  Vol.  iv.  p.  16. 

t Essays,  Physical  and  Literary,  Vol.  ii.  p.  39S. 

Medical  Comment.  Vol.  ix.  p.  278. 

§ Annals  of  Med.  Vol.  vi.  p.  296.  ||  Ib.  Vol.  vii.  p.  346. 

^ Transactions  of  a Society,  &c.  Vol.  ii.  p.  144. 

**  Med.  and  Surg.  Journal,  Vol.  ix.  p.  492. 

ft  Abstract  of  Cases  in  which  a Portion  of  the  Cylinder  of  the  Intestinal  Canal, 
comprising  all  its  coats,  has  been  discharged  by  stool.  Edin.  Med.  and  Surg.  Journ. 
xliv.  p.  296.  Edin.  1835. 

J J Des  Phlegmasies  des  Membranes  Muqueuses. 

§§  Practical  Remarks  on  Indigestion,  &c.  London,  1825. 


INTESTINAL  MUCOUS  MEMBRANE  IN  FEVER. 


647 


it  occurred  in  connection  with  fever;*  and  in  those  of  Godmanf 
and  VillermeJ  it  was  connected  with  chronic  inflammation  of  the 
gastric  mucous  membrane.  In  the  intestinal  canal  it  is  invariably 
the  consequence  of  some  degree  of  inflammatory  action. 

§ 1 Febrile  Gastro-enteria. — Gastro-enteric  inflammation  has  been 
considered  above  chiefly  as  a primary  and  idiopathic  disorder.  It 
is,  however,  not  unfrequently  observed  as  a concurrent  symptom 
or  effect  of  many  disorders  reputed  primarily  febrile.  This  was 
observed  long  ago  in  ague  and  remittent  fevers  by  Baglivi,  Sar- 
cone,  Roederer,  and  Wagler,  Stoll,  Selle,  and  others ; and  more 
recently  by  Pinel,  Broussais,  Petit,  and  Serres,  Andral,  Breton- 
neau,  and  Trousseau.  In  continued  fever  it  has  also  been  seen  by 
Andral,  Bretonneau,  and  Trousseau,  Louis,  and  Chomel,  and  by 
Cheyne,  Reid,  O’Brien,  and  Dr  Bright  in  this  country ; and  it  has 
been  more  or  less  fully  described  in  different  parts  of  Germany  by 
Killiches,  Frenzel,  Grossheim,  Ebel,  Stannius,  Kramer,  and  Les- 
ser. 

From  the  facts  collected  by  these  observers  it  results,  that  the 
action  of  fever  has  a peculiar  tendency  to  aflfect  the  mucous  sur- 
faces in  general,  and  especially  the  tracheo-bronchial  and  gastro- 
enteric membranes.  In  the  former  it  may  produce  the  anatomical 
characters  of  unequivocal  bronchial  inflammation,  proceeding  not 
unfrequently  to  the  first  stage  of  peripneumony.  Of  the  latter  it 
affects  more  or  less  intensely  diflFerent  regions.  In  some  it  aflPects  the 
gastric,  in  others  the  duodenal,  in  others  the  ileal  or  csecal,  and  in  a 
few  the  colic  mucous  membrane.  In  most  instances  the  membrane  is 
reddened  and  vascular,  thickened,  and  occasionally  softened.  (An- 
dral. ) In  many  it  assumes  the  form  of  red  or  brown  patches,  with 
or  without  ulceration.  In  many  the  mucous  membrane  is  occu- 
pied by  white  conical  elevations  half  a line  or  a line  high,  as  broad 
as  a lentil  at  base,  but  with  depressed  summits  like  the  pustules  of 
small-pox.  These  are  rare  in  the  jejunum  and  colon,  but  are  fre- 
quent in  the  two  lower  fifths  of  the  ileum.  (Andral.)  In  the  co- 
lon this  punctuate  inflammation  appears  in  the  form  of  broad  coni- 
cal bodies,  elevated,  with  pointed  tops,  of  a cherry-red  colour,  and 
injection  of  the  surrounding  membrane.  In  a large  proportion  of 
cases,  according  to  Bretonneau  and  Trousseau,  the  mucous  follicles 

* Clinique  Medicate,  &c.  Paris,  1823. 

t_The  Philadelphia  Journal,  1825. 

Archives  Generates,  Tome  xiv.  1827.  P.  6T4. 


648 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


are  enlarged,  reddened,  softened,  and  not  unfrequently  the  seat  of 


Andral,  who  maintains,  that,  though  these  bodies  are  highly  vascu- 
lar, and  pour  forth  an  augmented  secretion  when  the  mucous  mem-  ' 
hrane  is  inflamed,  yet  their  affording  the  commencement  of  intesti- 
nal ulcers  is  not  an  invariable  circumstance. 

I have  already  endeavoured  to  explain  the  circumstances  under 
which  follicular  inflammation  is  most  likely  to  take  place  in  fever. 
It  does  not  seem  to  be  necessarily  connected  with  typhous  fever ; 
and,  therefore,  the  fever  with  which  it  is  seen  in  connection  has  been 
denominated  typhoid  fever.  But  it  appears  to  be  rather  a remit- 
tent disorder,  to  be  endemic  in  certain  regions  and  localities,  and 
epidemic  in  certain  seasons. 

Though  the  frequency  of  ulceration  of  the  lower  extremity  of 
the  ileum  is  proportional  to  the  number  of  follicles,  ulceration  is 
exceedingly  rare  in  the  duodenum,  in  which  they  are  more  nume- 
rous, larger,  and  more  apparent  than  in  any  other  part  of  the  gas- 
tro-enteric  membrane.  From  the  observations  of  Dr  Bright, 
nevertheless,  and  the  facts  collected  by  Frenzel,  Stannius,  Choinel, 
Cruveilhier,  and  Lesser,  no  doubt  can  be  entertained  of  the  fact, 
that  inflammation  and  sloughing  of  the  mucous  follicles  is  a frequent 
cause  of  ulcers. 

The  comparative  frequency  of  ulcers  in  different  regions  of  the 
gastro-enteric  surface  during  fever  may  be  understood  from  the 
following  table,  in  which  Andral  gives  the  result  of  71  necroscopic 
inspections. 


Ulcers  of  the  Stomach  in 

Cases. 

10 

Caecum, 

Cases. 

15 

Duodenum, 

1 

Ascending  colon. 

4 

Jejunum, 

9 

Transverse  arch. 

11 

Lower  part  of  the 

Descending  colon,  . 

3 

ileum, 

38 

Rectum, 

1 

According  to  this  statement,  which  is  on  the  whole  accurate, 
ulcers  are  most  frequent  in  the  lower  end  of  the  ileum,  nearly  in 
the  proportion  of  one-half  of  the  cases,  next  to  this  in  the  caecum 
in  about  one-fifth  of  the  cases,  then  in  the  transverse  arch,  in  the 
stomach,  and  in  the  jejunum.  In  the  ascending  and  descending 
colon,  they  are  not  very  common,  and  in  the  duodenum  and  rectum 
extremely  rare.  Their  progress  and  effects  are  the  same  as  when 
taking  place  idiopathically. 

In  some  instances  of  fever,  Andral  remarked  that  portions  of  the 


INTESTINAL  MUCOUS  MEMBRANE  IN  SMALL-TOX. 


649 


intestinal  mucous  corlon  appeared  to  be  suddenly  struck  by  morti- 
fication, forming  a species  of  mucous  carbuncle,  {ardhraMon^)  and 
like  that  requiring  to  be  thrown  off  by  a long  process  of  ulceration. 
The  eschars  thus  discharged  left  ulcers  extensive  and  irregular. 
On  this  point  I refer  to  what  has  been  said  above  on  the  sloughs 
of  the  muciparous  follicles. 

§ 12.  Variolous  inflammation. — It  has  been  an  opinion  not  un- 
common, that  the  variolous  poison  produces  in  the  mucous  surfaces, 
and  especially  along  the  tract  of  the  gastro-enteric  mucous  mem- 
brane, pustules,  similar  to  those  of  the  skin ; and  sundry  instances 
of  papillcB,  pustules,  and  similar  bodies  in  the  stomach  or  intestines, 
recorded  by  Iheutaud,  have  been  supposed  to  give  countenance  to 
this  idea.  Upon  this  point,  however,  facts  are  something  discor- 
dant. 

1.  In  Mr  Heaviside’s  museum  is  a preparation  demonstrating 
the  appearance  of  numerous  genuine  pustules  of  the  mucous  mem- 
brane of  the  pharynx,  and  half  way  down  the  oesophagus.*  In 
one  subject,  in  like  manner,  Wrisberg  counted  14  distinct  pustules 
on  the  palatine  arch,  on  the  posterior  and  inferior  part  of  the  velum 
more  than  12,  and  many  in  the  neighbourhood  of  the  epiglottis., 
and  in  the  upper  part  of  the  pharynx,  but  observed  general  red- 
ness only  in  the  rest  of  the  oesophagus.  In  another  subject  he  ob- 
served on  the  mucous  surface  of  the  larynx  and  trachea  a crop  of 
singular  warty  eminences,  varying  in  size  from  a lentil  to  a grain 
of  hemp  seed,  round  or  oblong  in  shape.  These  bodies  Wrisberg 
states  he  took  care  to  distinguish  from  inflamed  mucous  follicles.f 
Sir  Gilbert  Blane,  to  tbe  same  effect,  records  an  instance  of  fatal 
confluent  small  pox,  in  which  the  whole  mucous  surface  of  the  oeso- 
phagus, stomach,  duodenum,  and  intestines,  to  the  rectum,  was 
found  beset  with  small  round  ulcerated  spots.  These  were  most 
crowded  in  the  duodenum,  and  in  the  colon.  They  were  dark- 
coloured  in  the  centre  like  cutaneous  pustules.  In  the  same  sub- 
ject, the  mucous  membrane  of  the  trachea  and  bronchia  was  occu- 
pied with  similar  ulcerated  spots.| 

2.  Notwithstanding  these  facts,  however,  which  are  accui-ately 
stated,  it  is  not  absolutely  certain  that  genuine  phlyctidia  have  even 

* Howship,  Observations,  p.  253. 

+ Henrici  Augusti  Wrisbergii,  D.  M.,  &c.  Commentationum,  Medici,  Physiolog. 
&c.  Argumenti.  Vol.  i.  Gottingse,  1800.  P.  52,  &c. 

t Some  Facts  and  Observations,  &c.  by  Gilbert  Blane,  M.  D.  Transactions  of  a 
Society,  Vol.  iii.  p.  425. 


650 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


been  seen  in  the  stomach  or  intestinal  membrane.  The  papillae 
and  pustule-like  eruptions  which  are  supposed  by  some  to  be  of 
this  nature  are  evidently  enlargements  of  the  mucous  follicles. 

3.  The  variolous  poison  certainly  produces  inflammation  of  the 
gastro-enteric  mucous  membrane ; but  this  consists  in  diffuse  red- 
ness and  injection,  or  red-brown  patches,  or  both,  generally  with 
some  affection  of  the  mucous  follicles.*  In  several  instances  of 
fatal  confluent  small-pox,  I have  seen  the  gastric  mucous  mem- 
brane deep  red,  much  loaded  with  vessels,  and  patches  of  extrava- 
sated  blood,  and  similar  appearances  with  bloody  mucus  in  vari- 
ous parts  of  the  ileum.  In  the  same  subjects,  the  tracheo-bron- 
chial  membrane  was  of  a deep-brown  colour,  and  highly  vascular. 

It  is,  indeed,  always  the  tracheo-bronchial  membrane  that  is 
most  affected  in  small-pox.  But,  excepting  at  the  epiglottis  and 
larynx,  it  presents  no  variolous  pustules.  The  larynx,  indeed,  usu- 
ally presents  the  appearance  of  mere  redness,  roughness,  and  swell- 
ing. In  one  case  of  fatal  confluent  small-pox,  in  which  the  pa- 
tient was  destroyed  before  the  eruption  came  completely  out,  I 
found  the  whole  mucous  membrane  of  the  trachea  and  the  large 
bronchi  covered  by  a thin  filmy  membrane  like  silver  paper,  and 
the  membrane  of  the  small  tubes  much  reddened.  In  other  cases 
in  which  the  patients  died  with  the  eruption  out,  the  whole  tracheo- 
bronchial membrane  was  red,  rough,  covered  with  viscid  mucus  ; 
and  the  small  bronchial  tubes  effused  large  quantities  of  frothy 
sero- mucous  fluid. 

These  phenomena  explain  the  severity  and  fatality  of  this  dis- 
ease. 

§ 1 3.  Tubercular  Disease  of  the  Ileum  and  Ileal  Follicles. — Before 
concluding  this  division,  I think  it  right  to  mention  here  a peculiar 
disorder  of  the  ileum  ; though  I am  not  certain  whether  it  ought  to 
be  referred  to  the  mucous  membrane,  the  peritoneum,  or  the  whole 
intestinal  tunics.  To  illustrate  the  nature  of  the  lesion  I give  the 
particulars  of  an  instance  of  the  disease  extremely  well  marked. 

A young  woman, f of  twenty  years,  had  laboured  for  some  time 
under  symptoms  of  disease  of  the  abdomen  ; and  at  length  the  ab- 


* “ The  pharynx  and  oesophagus  were  certainly  much  inflamed,  as  was  the  stomach, 
and  more  or  less  the  whole  of  the  intestines  ; but  after  the  most  diligent  search,  no 
trace  whatever  of  the  pustular  action  was  found  either  in  the  pharynx,  oesophagus, 
stomach,  or  intestines.”  Howship,  Observations.  See  also  Cotwrmii  syntagma,  &c. 
xliii.  xUx. 

■f  Under  the  care  of  Dr  Paterson  of  Leith. 

4 


INTESTINAL  MUCOUS  MEMBRANE. 


651 


doraen,  which  was  swelled  and  painful  at  certain  parts,  became  dis- 
tended, and  gave  evident  proofs  of  the  presence  of  fluid.  Dr  Pa- 
terson, under  whose  care  the  patient  was,  tried  for  some  time  all 
means  of  producing  the  absorption  of  this  fluid,  and  otherwise  re- 
moving the  disease  on  which  it  depended.  Little  or  no  effect,  how- 
ever, was  produced,  either  by  aperients,  diuretics,  or  local  appli- 
cations. Dr  Paterson  requested  me  to  see  her,  to  consider  the 
propriety  of  relieving  the  distension  and  other  sufferings  of  the  pa- 
tient, by  the  operation  of  parakentesis.  At  this  time  the  abdomen 
was  greatly  enlarged,  especially  towards  the  infra-umbilical  re- 
gion, where  it  emitted  a dull  sound,  and  gave  distinct  evidence  of 
fluctuation.  When  the  patient  was  placed  in  the  supine  position, 
there  was  something  peculiar  in  the  abdomen,  as  if  the  intestinal 
folds  were  more  consistent  than  natm'al,  and  adhered  in  certain 
points.  When  pressure  was  applied  slowly  and  carried  steadily 
downwards,  so  as  to  urge  the  intestines  towards  the  spine  and  pos- 
terior region  of  the  abdomen,  the  patient  gave  manifest  indications 
of  pain.  She  also  described  her  feelings  as  if  something  were  tied 
round  the  bowels.  It  was  clear,  nevertheless,  that  there  was  no 
adhesion  between  the  abdominal  parietes  and  the  intestinal  perito- 
naeum ; for  there  the  abdominal  fluid  was  interposed. 

After  careful  consideration  of  the  case,  it  was  agreed,  that,  as  no 
medicinal  agent  had  hitherto  made  any  decided  impression  on  the 
abdominal  swelling  or  the  contained  fluid,  it  was  desirable  to  empty 
the  abdomen  by  operation,  and  then  try  the  eflfect  of  remedies. 

The  operation  was  accordingly  performed,  and  about  nineteen 
or  twenty  pints  of  serous  and  sero-purulent  fluid  withdrawn.  The 
operation  was  well  borne ; and  the  patient  was  replaced  in  bed. 

The  wound  healed  in  a few  days,  and  the  patient  seemed  to  recover 
from  the  immediate  effects  of  the  operation.  But  in  the  course  of 
a few  days  vomiting  came  on  and  death  ensued. 

Inspection  disclosed  the  following  appearances. 

In  the  lumbar  and  iliac  fossae  and  in  the  pelvis  there  was  some 
sero-purulent  fluid,  with  a few  albuminous  flakes.  A little  accu- 
mulation had  taken  place  since  the  operation. 

The  omentum  was  drawn  up  and  shrivelled,  though  thickened. 

All  the  folds  of  the  ileum,  which  came  into  view,  adhered  to  each 
other  intimately  by  albuminous  exudation,  so  that  not  one  portion 
of  the  ileum  could  be  said  to  be  in  its  natural  free  position.  Even 
some  of  the  lower  pai'ts  of  the  jejunum  adhered  in  this  manner. 
The  tunics  of  the  ileum  were  thickened,  indurated,  and  in  certain 


652 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


parts  where  the  adhesions  were  most  firm  and  intimate,  they  were 
of  cartilaginous  consistence. 

The  ileum  was  cut  open  longitudinally,  and  the  true  state  of  the 
disease  was  then  seen. 

At  intervals  of  from  six  to  eight  or  nine  inches  the  mucous 
membrane  of  the  ileum  presented  large  irregular  ulcerated  open- 
ings, penetrating  directly  through  all  the  coats  to  the  perituncBum, 
then  from  the  peritonaeum  of  the  corresponding  adherent  portion  of 
ileum,  through  the  coats  of  that  portion  to  the  mucous  membrane. 
By  these  openings  direct  passages  had  been  formed  from  one  por- 
tion of  bowel  through  the  coats  into  the  attached  portion. 

These  openings  were  in  shape  mostly  elliptical  or  oval,  with  the 
long  diameter  corresponding  to  the  axis  of  the  bowel.  Their 
edges  were  ragged  and  irregular  ; and  while  the  intestinal  tissues 
around  them  were  thickened  and  cartilaginous,  the  capacity  of  the 
bowel  was  much  diminished. 

In  size  the  openings  varied  from  half-an-inch  to  one  inch  or  one 
inch  and  a-half  in  the  long  diameter.  Their  breadth  was  from 
half-an-inch  to  three-fourths. 

The  number  of  these  openings  was  considerable.  There  were 
at  least  20,  and  probably  more. 

On  examining  the  lines  of  adhesion  by  which  they  were  con- 
nected, tubercular  matter  was  visible  both  at  the  peritoneal  and 
mucous  surface,  and  in  several  parts  of  the  peritonaeum  small  tu- 
bercular bodies,  white  and  opaque,  were  deposited.  It  was  not  easy 
to  say  whether  these  bodies  had  commenced  at  the  peritoneal  or  at 
the  mucous  surface.  They  were  in  general  covered  by  peritonaeum, 
and  they  were  as  distinct  at  the  mucous  surface  as  at  the  serous. 

A case  similar  to  this  is  given  by  Dr  George  Gregory.* 

An  important  inquiry  suggested  by  cases  of  this  class  is  to  de- 
termine where  the  ulceration  originates  ; whether  at  the  mucous  or 
at  the  peritoneal  surface  of  the  bowel.  The  point  is  not  one  of 
very  easy  determination. 

It  seems,  on  the  one  hand,  most  natural  to  think  that  the  ulcera- 
tion began  at  the  mucous  surface.  To  me  these  ulcerated  open- 
ings appear  to  be  in  the  site  of  the  agminated  patches  of  Peyer. 
These  patches  w'ere,  I infer,  originally  penetrated  or  infiltrated  with 
tubercular  matter.  They  had  then  proceeded  to  softening  and  ul- 
ceration, destroying  of  course  the  mucous  and  other  tissues  slowly 

* Observations  on  the  Scrofulous  Inflammation  of  tlie  Peritonaeum,  &c.  Med. 
Chir.  Trans,  xi.  p.  258. 


GENITO-URINARY  MUCOUS  MEJIBRANE. 


653 


and  progressively.  When  this  destroying  action  arrived  at  the 
peritoncEum,  it  caused  first  adhesion  of  that,  or  rather  adhesive  in- 
flammation, connecting  it  to  the  peritoncBum  of  the  corresponding 
portion  of  ileum,  and  then  proceeded  by  the  same  ulcerative  action 
to  destroy  the  tunics  of  that  portion  of  bowel,  though  in  the  oppo- 
site direction ; that  is,  first,  peritonaeum,  then  cellular  and  muscular 
tissue,  then  cellular  and  mucous  membrane. 

This  view  of  the  course  of  the  disorder  is,  nevertheless,  not  without 
difficulty.  It  supposes  the  process  of  tubercular  deposition  and  ul- 
ceration to  advance  first  from  the  mucous  to  the  peritonmal  surface 
of  a portion  of  ileum,  and  then  from  the  peritonaeal  to  the  mucous 
surface ; or  that  the  process  was  advancing  simultaneously  from 
the  mucous  membranes  of  two  applied  portions  of  ileum  to  the  peri- 
tonaea! until  they  met  in  the  latter  point. 

Notwithstanding  these  difficulties,  this  view  appears  more  pro- 
bable, than  that  the  disease  had  commenced  in  the  peritonceum,  and 
thence  proceeded  to  affect  the  other  intestinal  tissues  to  the  mucous 
membrane.  The  ulcerated  openings  also  corresponded  in  figure 
and  size  with  the  patches  of  agminated  glands. 

Dr  George  Gregory  takes  the  opposite  view ; and  his  case  I 
therefore  refer  to  the  head  of  lesions  of  the  peritonaeum. 

D. THE  GENITO-URESTARV  MUCOUS  MEMBRANE. 

§ 1.  The  genito-urinary  mucous  membrane  in  both  sexes  is  the 
seat  of  sundry  forms  of  the  inflammatory  process. 

The  urethral  membrane,  though  forming  a part  of  this  surface, 
possesses,  nevertheless,  certain  anatomical  and  sensible  peculiari- 
ties. Smooth,  and  even  polished,  moistened  by  a thin  transparent 
fluid,  it  is  formed  into  the  sinuosities  named  lacunae,  which,  like  the 
follicles  of  other  membranes,  secrete  a fluid  of  a peculiar  odour, 
which,  united  with  that  of  the  general  membrane,  serves  to  lubri- 
cate the  surface.  Examined  from  its  opening  to  its  cystic  extre- 
mity, it  presents  divisions  which  may  be  enumerated  in  the  follow- 
ing order,  the  spongy,  the  bulbous,  the  membranous,  and  the  pro- 
static or  vesical  portions,  according  to  the  parts  of  the  canal  to 
which  the  membrane  is  attached.  This  membrane  may  be  the  seat 
of  inflammation  of  two  sorts ; — one  circumscribed  and  unsuppura- 
tive,  the  other  spreading,  and  accompanied  with  secretion  of  puri- 
form  or  purulent  matter,  more  or  less  abundant. 

a.  Urethria  simplex. — Common  inflammation  of  the  urethra  con- 


654 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


sists  in  redness,  swelling,  and  pain  of  a certain  part  of  the  canal, 
which  thus  is  rendered  very  narrow,  or  even  may  undergo  tempo- 
rary and  partial  obliteration.  This  affection  is  attended  with  pain- 
ful tension  of  part  or  the  whole  of  the  penis,  suppression  of  urine, 
sometimes  priapism,  and  consitutional  disturbance  proceeding  at 
once  from  local  irritation,  and  the  distress  occasioned  by  difficulty 
of  voiding  the  urine,  or  by  its  total  suppression.  This  form  of 
urethral  inflammation  should  be  distinguished  from  stricture,  with 
which  it  is  too  often  confounded.  Instead  of  spreading  along  the 
membrane,  it  has  a tendency  to  pass  to  the  submucous  tissue,  and 
thicken  it.  It  is  probable  that  it  may  occur  in  any  part  of  the 
canal ; but  its  most  ordinary  site  is  the  membranous  portion.  If 
properly  treated,  it  terminates  in  resolution  with  a gleety.discharge, 
in  effusion  of  lymph  or  suppuration,  not  unfrequently  with  fistulous 
openings. 

b.  Urethria  puriformis  ; Gonorrhaa  ; Medorrlio^a. — That  the 
fluid  of  gonorrhoea  is  of  inflammatory  origin  is  proved  by  the  swell- 
ing of  the  urethral  orifice,  the  pain  and  tenderness  of  the  canal, 
and  the  sore  or  scalding  sensation  (ardor  iirince)  occasioned  by  the 
transit  of  the  urine  over  it.  At  an  early  period  of  the  art,  when 
pathological  knowledge  was  defective  or  erroneous,  this  discharge 
from  the  urethra  was  believed  to  consist  of  seminal  fluid,  and  to  is- 
sue from  the  organs  by  which  that  fluid  is  secreted.  Afterwards, 
when  medical  practitioners  understood  the  nature  of  the  discharge 
as  distinct  from  seminal  fluid,  it  was  believed  to  be  purulent  matter 
issuing  from  ulcers  in  the  canal.  This  opinion,  which,  indeed,  was 
more  rational,  was  nevertheless  completely  disproved,  first  by  Mor- 
gagni,* and  afterwards  by  John  Hun  ter,  f who  showed  by  dissection 
of  persons  whose  death  had  occurred  while  they  were  labouring 
under  urethral  discharge,  that  though  minute  ulcers  may  occasion- 
ally be  found  in  the  canal,  they  are  totally  unconnected  with  the 
discharge,  which  in  the  greater  number  of  cases  is  secreted  by  the 
urethral  membrane  in  a state  of  inflammation.  According  to  the 
most  accurate  observations  several  regions  of  the  urethral  mucous 
membrane  may  without  ulceration  or  erosion  furnish  puriform  se- 
cretion. 

The  first  of  these  is  the  hollow  named  navicular  fossa,  about  1, 
1^,  or  2 inches  from  the  orifice,  or  the  anterior  end  of  the  spongy 

* Adversaria  Anatom.  Epistola  xliv.  1,  2. 

-f-  Treatise  on  the  Venereal  Disease,  Part  ii.  Chap.  1. 


GENITO-URINARY  MUCOUS  MEMBRANE. 


655 


portion  of  the  membrane.  This  region  abounds  with  the  canaliculi, 
to  which  Morgagni  traced  the  secretion  ; and  in  the  dissections  of 
John  Hunter  it  was  uniformly  found  redder,  and  more  vascular 
or  blood-shot  than  usual,  and  the  lacunas  often  filled  with  matter. 
Secondly,  in  cases  in  which  the  inflammation  is  more  extensive,  the 
membranous  part  of  the  canal,  Cowper’s  glands  and  their  ducts, 
are  involved  in  the  morbid  process.  This,  however,  is  exceedingly 
rare,  according  to  Littre,  Morgagni,  and  Baillie.  The  first,  after 
inspecting  forty  cases  of  urethral  inflammation,  found  in  one  case 
only  the  glands  of  Cowper  morbid.  Morgagni  met  with  one  or 
two  instances  only  ; and  J ohn  Hunter  remarks,  that  if  the  matter 
of  clap  were  secreted  and  deposited  either  beyond  or  in  the  bulb, 
it  would  be  incessantly  ejected  by  the  muscles,  as  occurs  in  regard 
to  the  urine  and  seminal  fluid.  In  cases  yet  more  extensive,  the 
prostatic  part  of  the  urethra  has  been  known  to  be  inflamed  ; and 
in  very  violent  forms  of  clap,  the  inflammation  has  been  found  to 
extend  to  the  bladder  itself.  It  thus  appears  that  no  portion  of 
the  canal,  from  its  orifice  to  the  neck  of  the  bladder,  is  exempt  from 
inflammation  ; and  every  part  of  the  membrane  between  these  two 
points  has  been  found  more  or  less  reddened,  slightly  villous,  vas- 
cular, and  more  or  less  swelled,  so  as  to  diminish  sensibly  the  cali- 
bre of  the  canal.  It  is  observed  by  Dr  Baillie,  that  the  inflamma- 
tion may  pass  from  the  mucous  to  the  submucous  membrane,  and 
the  surrounding  tissue  of  the  spongy  body,  which  thus  becomes 
larger  and  harder,  in  consequence  of  loaded  vessels  and  effused 
lymph,  than  in  the  natural  state.  It  is  not  improbable  that  this 
morbid  state  of  the  spongy  body,  by  irritating  the  ischio-cavernosi 
muscles,  and  exciting  them  to  action,  gives  rise  to  the  painful  af- 
fection denominated  cliordee. 

The  glands  of  Cowper  have  been  seen  indurated  and  like  tuber- 
cles, in  consequence  of  inflammation  ; occasionally  their  ducts  are 
rendered  impervious,  and  in  some  instances  ulcers  take  place.  And 
in  some  instances  the  effect  of  this  process  is  to  obliterate  both  the 
longitudinal  folds  and  the  canaliculi  of  Morgagni.  Ulceration,  to 
which  Morgagni  himself  had  recourse,  is  not  requisite  to  explain 
this  occurrence,  which  may  be  affected  by  inflammatory  thickening 
of  their  membrane.  When  the  inflammation  terminates  in  effusion 
of  lymph  into  the  submucous  tissue,  the  swelling  induces  that  con- 
traction of  the  canal  which  constitutes  stricture. 

§ 2.  Cystidia.  Cystirrhcea. — The  cystic  mucous  membrane,  like 


656 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  urethral,  is  liable  to  inflammation  either  over  its  whole  extent 
or  at  a single  spot.  The  part  most  frequently  affected  is  the  neck 
of  the  bladder  and  the  space  termed  cystic  triangle  (la  trigone  vesi- 
cate') ; a circumstance  which  has  been  ascribed  to  one  of  two  causes. 
The  first  is,  that  the  neck  is  most  usually  affected  by  mechanical 
obstructions  to  the  passage  of  the  urine,  and  is  therefore  most 
likely  to  be  the  first  seat  of  the  irritation  which  connects  injuiy 
and  inflammatory  action.  The  other  is,  that  its  contiguity  to  the 
urethra  renders  it  liable  to  be  first  affected  by  inflammation  of  that 
canal  when  disposed  to  spread,  or  when,  in  consequence  of  bad 
treatment,  chronicity,  or  other  causes,  urethral  becomes  an  exciting 
cause  of  cystic  inflammation. 

From  either  of  these  causes,  inflammation  may  be  developed  in 
the  cystic  mucous  surface  near  the  neck  of  the  bladder,  and  may 
thence  be  propagated  over  a considerable  extent  of  the  membrane, 
which  then  becomes  marked  by  red  points,  villous,  highly  vascular, 
and  diffusely  swelled,  with  occasional  spots  of  extravasated  blood. 
In  general,  the  character  of  this  inflammation  is  to  spread ; and  in 
ordinary  cases  it  does  so  without  affecting  the  submucous  or  other 
tissues.  Instances,  however,  occur,  in  which  it  passes  successively 
to  the  submucous  filamentous  tissue,  to  the  muscular,  and  thence 
to  the  peritoneal  coat.  In  the  spreading  form  the  inflammation  is 
attended  with  secretion  of  thick  mucous  or  puriform  fluid,  which 
falls  to  the  bottom  of  the  urine. 

It  may  terminate  in  resolution,  in  suppuration,  in  destruction  of  the 
coats  or  ulceration ; or  lastly,  it  may  pass  into  the  chronic  state. 
The  manner  in  which  the  two  first  terminations  are  effected,  is  in 
every  respect  similar  to  these  processes,  as  they  take  place  in  other 
mucous  surfaces. 

The  third,  or  ulceration  of  the  mucous  and  other  tissues  of  the 
bladder,  is  not  uncommon,  and  may  occur  under  two  forms.  In 
the  first,  which  is  most  common,  it  may  be  superficial,  and  remove 
the  whole  mucous  membrane  so  as  to  expose  tbe  muscular  layer  as 
if  it  bad  been  neatly  dissected.  In  the  second,  which  is  more  usual, 
the  ulcerative  process  advances  in  minute  patches  from  the  mucous 
to  the  submucous  and  muscular  tissues,  and  in  some  instances  to 
the  subserous  and  peritoneal  membrane.  This  process  differs  from 
the  other  in  this  respect,  that  lymph  is  irregularly  deposited,  that 
there  is  considerable  swelling,  and  sometimes  a true  abscess  is 
formed.  More  frequently,  however,  small  portions  of  the  mucous 

3 


MUCOUS  MEMBRANE. 


657 


membrane  are  detached  in  isolated  points  by  ulceration  ; and  though 
the  subjacent  tissues  are  exposed,  there  is  no  regular  cavity  or 
abscess,  but  merely  an  ulcerated  depression,  which  secretes  puru- 
lent matter.  (Walter.)  In  more  severe  cases,  in  which  the  suppu- 
rative or  ulcerative  process  penetrates  the  different  coats,  commu- 
nications are  formed  between  the  bladder  and  the  neighbouring 
parts.  The  most  ordinary  of  these  modes  of  communication  are 
the  general  peritoneal  cavities,  or  the  rectum,  in  both  sexes,  and 
the  vagina  in  the  female.  In  the  first  case,  besides  other  symptoms* 
the  urine  gives  rise  to  fatal  peritoneal  inflammation ; in  the  second 
and  third,  its  escape  by  unnatural  passages  induces  much  local  ir- 
ritation and  general  distress,  and  eventually  may  terminate  in  death< 
Sloughing  of  the  cystic  mucous  membrane,  has  been  known  to  oc- 
cur, but  is  not  common. 

b.  Cystidia  Diuturna. — The  termination  of  cystidia  in  the  chro- 
nic form  is  most  frequent  in  those  who  have  laboured  under  re- 
peated attacks  of  acute  cystic  inflammation ; those  who  have  had 
urethral  or  prostatic  inflammation,  or  other  disease  of  these  parts ; 
those  having  urethral  stricture ; those  liable  to  sabulous  or  lithie 
concretions,  or  wherever  there  is  a permanent  cause  of  irritation. 
It  is  hence  common  in  persons  whose  health  is  impaired,  or  who 
are  advanced  in  life.  The  cystic  membrane  becomes  not  only  red- 
dish, but  brown,  villous,  flocculent,  and  considerably  thickened. 
In  some  instances  it  become  granular  and  unusually  hard.  This 
change  was  repeatedly  seen  by  Hoffmann,  Morgagni,*  Lieutaudj 
Portal,  and  others ; and  it  is  important  to  remark,  that  it  never 
continues  long  without  causing  inordinate  thickening  of  the  mus- 
cular layer,  and  occasionally  irregular  contraction  of  its  constituent 
fibres,  so  as  to  form  sacculi^  or  cavities  in  the  walls  of  the  organ. 
In  most  instances  it  secretes  puriform  mucus,  (Hoffmann,  Chopart,) 
but  without  destruction  of  the  mucous  membrane.  The  former  au- 
thor relates  an  instance  in  which  the  usual  effects  took  place,  while, 
upon  inspection,  the  cystic  tissues  were  found  thickened  and  condens- 
ed, and  the  vessels  of  the  mucous  membrane  large,  numerous,  and 
loaded,  yet  without  trace  of  ulceration.  This  disorder  is  said  to 
have  been  the  cause  of  death  to  Voltaire,  Buffon,  D’Alembert,  and 
Spallanzani.!  On  the  other  hand,  the  mucous  membrane  may  be 
entirely  removed,  as  in  the  acute  form,  by  a process  of  ulceration 

* Epist.  xlii, 

t Brera  Storia  della  Malattia  di  P.  Spallanzani. 

T t 


658 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


or  sloughing.  In  the  case  of  Professor  Barthez  of  Montpellier, 
recorded  by  M.  Double,*  the  cavity  of  the  organ,  which  contained 
a mulberry  calculus  nine  lines  in  diameter,  was  diminished  and 
filled  with  purulent  matter  ; its  walls  were  black  and  sphacelated  ; 
of  mucous  membrane  not  a trace  was  left,  and  the  muscular  coat 
was  thickened.!  From  a similar  action  results  the  villous,  fun- 
gating, and  granular  state  of  the  bladder  observed  by  Ruysch, 
Walter,  Baillie,  and  others-! 

The  anatomical  characters,  in  short,  of  this  disease  in  its  exqui- 
site form  are  the  following.  The  walls  of  the  organ,  especially  its 
muscular  coat,  are  thickened,  hardened,  and  as  if  hypertrophied  ; 
and  the  muscular  thickening,  as  well  as  the  cellular,  may  be  consi- 
derable, that  is  to  say,  approaching  to  half  an  inch.  The  cavity  of  the 
organ  is  much  contracted,  sometimes  not  larger  than  the  capacity 
of  a small  egg.  The  mucous  membrane  is  very  commonly  red- 
dened and  Vciscular  all  over  or  in  patches ; in  some  instances  it  is 
partially  removed  by  ulceration  ; and  in  some  instances  it  is  entirely 
removed,  as  if  it  bad  been  dissected  away  from  the  muscular  coat. 
This  I have  several  times  seen  ; and  in  general  the  exposed  surface 
was  covered  with  patches  of  calcareous  matter,  which  was  either 
ammoniaco-magnesian  phosphate,  phosphate  of  lime,  or  carbonate 
of  lime. 

The  effects  of  this  process  is  to  alter  considerably  the  ordinary 
secretion  of  the  cystic  mucous  membrane.  The  cystic  mucus  in  the 
healthy  state  is  a thin  fluid,  easily  miscible  with  the  urine,  and  so 
trifling  in  quantity,  at  least  in  the  urine  discharged,  that  it  is  rarely 
observed.  What  is  called  cloudy  urine  generally  contains  a little 
more  of  this  mucous  matter  than  usual.  In  the  inflamed  state  it 
appears  in  the  form  of  thick,  opaque,  viscid  fluid,  which  falls  to  the 
bottom  of  the  vessel,  and  in  very  severe  cases  it  is  puriform,  or  pu- 
rulent fluid,  opaque  and  milky,  but  not  ropy,  and  is  occasionally 
reddish  or  streaked  with  blood.  To  account  for  the  origin  of  this 
morbid  secretion,  Fanton  conceived  that  follicles  or  mucous  glands 
of  the  cystic  membrane  became  inflamed,  and  increased  their  na- 
tural action.§  The  existence  of  such  bodies  in  this  membrane  is 
nevertheless  questionable ; and  it  is  unnecessary  to  look  for  any 

■*  Hist.  Anatom.  Med.  Obs.  1224,  1266,  1270,  1272,  1274. 

t Journal  Generate  de  Medecine.  Nov.  1806. 

J F.  A.  Walter,  Einige  Krankheiten  der  Nieren  und  Hamblase  untersuclit  u.  s.  w. 
Berlin,  1800.  P.  31. 

§ Dissert.  Anatom.  174,5. 


4 


MUCOUS  MEMBRANE, 


659 


other  tissue  save  the  mucous  surface  to  explain  the  origin  of  the 
discharge. 

The  truth  is,  that,  as  soon  as  the  mucous  membrane  of  the  bladder 
begins  to  secrete  puriform  matter,  this  alters  much  the  chemical  pro- 
perties of  the  urine.  Ammonia  is  secreted ; or  rather  the  urea  is 
decomposed  and  converted  into  ammonia  or  carbonate  of  ammonia ; 
and  either  the  urine  contains  ammoniaco-magnesian  phosphates,  or 
some  other  aramoniacal  salt. 

The  other  effects  of  this  disease  are  weight,  uneasiness,  and  some- 
times tension  in  the  hypogastric  region  ; heat  in  voiding  the  urine  ; 
uneasy  parched  condition  of  the  skin  of  the  legs  and  feet,  with  burn- 
ing of  the  soles ; thirst,  quick  pulse,  impaired  appetite,  and  general 
wasting.  The  constitutional  disturbance  and  wasting  generally 
prove  fatal  directly,  or  by  inducing  some  fatal  disease. 

Membranous  substances  have  been  observed  to  be  discharged 
fi’om  the  bladder  by  Willis,  Ruysch,  Boerhaave,  and  Moi'gagni. 
According  to  the  account  of  the  inspections,  these  are  stated  to  be 
portions  of  the  mucous  membrane  of  the  bladder.  Though  I feel 
difficulty  in  denying  the  testimony  of  observers  so  competent,  I feel 
equal  difficulty  in  admitting  this  exfoliation,  which  is  indeed  ana- 
logous to  the  exfoliations  of  the  intestinal  mucous  membrane.  It 
is  equally  possible,  and  not  altogether  improbable,  that  these  mem- 
branous substances  were  albuminous  concretions  from  the  inflamed 
cystic  membrane. 

§ 3.  The  utero-vaginal  mucous  membrane  of  the  female  is  not 
less  important  as  a seat  of  morbid  action. 

The  labio-vaginal  mucous  membrane  is  often  the  seat  of  gonor- 
rhcsal  inflammation,  which  seems  to  produce  in  it  much  the  same 
effects  as  in  the  male  urethra.  In  severe  cases  the  nym-plia:  swell 
so  m_uch  that  they  make,  with  the  external  labia^  one  shapeless  mass. 
The  vaginal  membrane  I have  seen  the  seat  of  a thick  yellow  puri- 
form discharge,  which  was  positively  asserted  to  be  unconnected 
with  gonorrhoeal  infection.  This,  however,  requires  further  confir- 
mation. In  all  cases  the  membrane  becomes  so  much  swelled  that 
the  rugce  are  to  a certain  extent  obliterated.  The  lacuna  are 
stated  to  be  the  chief  source  of  the  discharge  when  thick  and  puri- 
form. 

The  uterine  mucous  membrane  is  liable  to  various  forms  of  the 
inflammatory  process,  most  of  which,  however,  may  be  referred  to 


G60 


GEXERAL  AND  PATHOLOGICAL  ANATOMY. 


three  heads, — the  spreading  sero-mucous  or  puriform,  the  limited  or 
suppurative,  and  the  albuminous. 

Of  the  spreading  inflammation  there  are  two  varieties,  one  with 
transparent  mucous  discharge,  the  other  with  opaque  or  white  mu- 
cous discharge. 

In  the  first  case,  in  which  a transparent,  gelatinous,  imperfectly 
coagulable  fluid  issues  from  the  vagina,  the  uterine  mucous  mem- 
brane is  in  a state  of  chronic  congestion,  and  the  organ  itself  becomes 
slightly  enlarged.  This  discharge,  which  issues  from  the  mucous 
surface  of  the  womb,  and,  according  to  Leake,  from  the  same  vessels 
which  are  subservient  to  menstruation,  constitutes  a large  propor- 
tion of  the  cases  regarded  as  Jluor  albus.  It  takes  place  as  a symp- 
tom of  prolapse  of  the  womb,  bladder,  or  vagina,  of  inversion  of 
the  womb,  of  cancer,  polypus,  and  even  warty  growths  of  the  or- 
gan.* 

In  the  second  form,  though  the  disease  may  affect  the  mucous 
surface  in  general,  its  more  particular  seat  is  the  cervix  of  the  womb  ’ 
and  its  mucous  glands.  It  was  observed  originally  by  Morgagni,f^ 
and  afterwards  by  Leake,  that  in  certain  forms  of  Jluor  albus  in-  f 
cident  to  young  females  of  8 or  10  years  old,  the  discharge  pro-  ' 
ceeds  from  the  mucous  glands  of  the  womb.  By  observing  pain  -i 
and  tenderness  uniformly  in  this  part,  Mr  C.  M.  Clarke  confirms'- 
the  accuracy  of  this  observation.  It  causes  to  issue  from  the  va-  ’ 
gina  an  opaque  perfectly  white  fluid,  resembling  a mixture  of ' 
starch  and  water  made  in  the  cold,  or  thin  cream,  easily  washed 
from  the  finger,  and  diffusible  in  water,  which  it  renders  turbid,  ' 
sometimes  tenacious,  like  melted  glue. 

3.  When  the  raucous  membrane  of  the  womb  or  vagina  is  in-  ? 
flamed,  it  may  secrete  puriform  or  purulent  fluid,  which  is  not  un- 
frequently  retained  within  the  cavity  of  the  organ.  Collections  of  ^ 
purulent  matter  in  the  former  have  been  recorded  by  Lieutaud,J 
Portal,§  Dr  Clarke, ||  and  others.  Of  these  collections  the  pecu-  i 
liarity  is  that  they  are  not  discharged  as  they  are  formed, — a cir-  I 
cumstance  which  is  in  general  to  be  ascribed  to  obstruction  of  the 
uterine  orifice  by  lymph.  This,  it  is  to  be  remarked,  is  accidental, 

* Observations  on  those  Diseases  of  Females  which  are  attended  by  Discharges,  &c. 
&c.,  by  Charles  Mansfield  Clarke.  Part  i.  Lond.  1814,  and  Part  ii.  Lond.  1821. 

+ Epist.  xlvii.  14,  15,  18.  J Hist.  Anatom.  Med. 

§ Anatomie  Meddcale,  Tom.  v.  p.  519. 

II  Transactions  of  a Society,  Vol.  iii.  p.  560. 


MUCOUS  MEMBRANE. 


661 


and  does  not  establish  an  essential  or  specific  difference  between  such 
purulent  collections  and  those  discharges  which  take  place  from 
the  orifice  of  the  organ.  It  is  nevertheless  to  be  remarked,  that 
these  collections  partake  in  a more  conspicuous  degree  of  the  cha- 
racters of  genuine  active  inflammation  of  the  uterine  mucous  sur- 
face. 

Puriform  inflammation  of  the  utero-vaginal  mucous  membrane 
is  to  be  distinguished  from  abscess  of  the  lahia^  or  nymph(B^  from 
suppuration  of  the  submucous  vaginal  tissue,  which  I have  seen  take 
place  under  circumstances  that  might  lead  them  to  be  confounded 
with  each  other,  from  gonorrhoeal  inflammation,  fi’om  corroding 
ulcer  of  the  mouth  of  the  womb,  and  from  cancer  of  the  womb  or 
of  the  rectum. 

The  second  general  form  of  uterine  mucous  inflammation  is  that 
in  which  the  product  of  the  process  is  an  albuminous  membranous 
concretion.  Morgagni  records  a good  instance  of  redness  of  the 
uterine  mucous  membrane,  part  of  which  was  at  the  same  time 
lined  by  a preternatural  membranous  substance.  It  has  been 
further  long  known,  that  many  females  discharge  periodically  shreds 
and  portions  of  membranous  matter  of  various  size  and  shape,  and 
some  so  large  that  they  form  almost  complete  moulds  of  the  inner 
uterine  surface.  These  facts,  which  were  observed  by  William 
Hunter,  Leake,  Denman,  and  Hulme,  are  well  known  to  acou- 
cheurs  and  those  conversant  with  the  management  of  female  dis- 
orders. It  may  be  stated  as  a wdl  established  fact,  that  these  mem- 
branous productions  are  analogous  to  those,  which  I have  above 
shown,  are  secreted  by  other  mucous  surfaces ; and  that  their  for- 
mation is  connected  with  an  inflammatory  state  of  the  uterine  mu- 
cous membrane.  Independent  of  the  fact,  that  their  formation  is 
attended  with  pain  of  the  uterine  region  and  disturbed  function,  in 
some  favourable  instances  in  which  inspection  has  taken  place,  the 
transition  from  fluid  to  solid  state  has  been  traced,  and  the  congest- 
ed state  of  the  uterine  vessels  demonstrated.  In  sundry  instances, 
nevertheless,  these  membranous  productions  are  formed  by  that  ac- 
tion of  the  vessels  which  constitutes  menstruation,  and  they  are 
formed  chiefly  at  the  menstrual  periods.  In  all  cases,  their  forma- 
tion implies  a state  of  the  uterus  incompatible  with  impregnation  ; 
and  sterility  is  the  accompaniment  of  this  disease. 

§ 4.  Adhesive  inflammation  of  the  Vaginal  Mucous  Membrane. 
— It  has  been  observed  by  Baillie,  that  the  vagina  is  liable  to  a vio- 


662 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


lent  form  of  inflammation,  which,  by  producing  effusion  of  lymph, 
causes  mutual  adhesion  of  the  sides  of  the  canal.*  By  Howship, 
this  is  ascribed  to  excoriation  between  the  labia^  causing  at  an  early 
age  effusion  of  lymph,  so  as  to  resemble  aphthce  ; and  he  mentions 
an  instance  in  a child  of  two  months,  in  which  lymph  had  been  se- 
creted, and  had  become  vascular,  leaving  a minute  aperture  for  the  | 
urine  at  the  inferior  angle  of  the  vagina.f  If  these  two  forms  of 
inflammation  be  different,  the  latter  is  probably  of  the  same  nature  j 
as  that  now  to  be  mentioned. 

§ 5.  Sloughing  inflammation  of  mucous  surfaces. — To  this  head 
I refer  two  varieties  of  disease  met  with,  particularly  at  the  com- 
munication of  the  two  great  mucous  surfaces  with  the  skin. 

The  first  is  the  disease  originally  described  by  HoflPmann  and 
Van  Swieten  under  the  name  of  cancrum  oris,  the  water  canker  of 
Dr  Robert  Hamilton  of  Lynn  Regis,:}:  and  more  recently  by  Dr 
M.  Hall,§  Dr  Thomas  Gumming,  ||  and  various  subsequent  observ- 
ers. In  this  disease  the  mucous  membrane  of  the  mouth,  cheek,  I 
or  gums,  becomes  hot,  swelled,  of  a dark-red  colour,  and  eventu- 
ally black,  hard,  and  dead.  The  mortified  portion  begins  then  to 
be  thrown  off ; but  in  the  meantime  the  original  inflammatory  pro- 
cess advances ; and  combined  with  that  necessary  for  ejecting  the  ' 
sloughs,  is  accompanied  with  extreme  pain,  and  much  constitutional 
disturbance.  Though  this  disorder  has  been  thought  to  originate  j 
in  the  skin,  in  which  it  appears  when  presented  to  the  practitioner, 
it  may  always  be  traced  to  the  mucous  membrane  of  the  mouth  ; a | 
fact  which  is  properly  verified  by  the  observation  of  Dr  Gumming. IF  j 

The  second  variety  of  this  disease  is  seen  in  the  pudendum  of  | 
young  girls,  in  whom  the  labial  or  valvular  membrane  is  liable  to  j 
a species  of  diffuse  inflammation,  which  almost  invariably  terminates  i 
in  mortification  of  the  mucous  corion,  which  is  then  cast  in  the 
form  of  slough.  According  to  the  observations  of  Mr  Kinder 
Wood,  to  w'hom  we  are  indebted  for  the  most  distinct  account  of 
this  disorder  yet  published,  the  labial  mucous  menlbrane  becomes 
of  a dark  red  colour,  swelled,  and  covered  by  numerous  watery  ve- 
sicles or  aphthcE,  the  cuticle  of  which  dropping  off  discloses  deep 

* Morbid  Anatom)',  Chap.  xxii.  p.  415. 

Practical  Observations,  &c.  Chap.  vi.  p.  360. 

J Apud  On  the  Marsh  Remittent  Fever,  &c.  London,  1801. 

§ Bdin.  Medical  and  Surgical  Journal,  Vol.  xv. 

II  Dublin  Hospital  Reirorts,  Vol.  iv.  p.  330. 

Ibid.  p.  335. 


MUCOUS  MEMBRANE. 


663 


foul  ulcers,  surrounded  with  much  redness,  and  secreting  thin  of- 
fensive matter.  Similar  aphthae  also  appear  on  the  skin  of  the 
mans  veneris,  perinceum,  and  adjoining  parts.*  Though  the  disease 
is  often  fatal  by  the  severity  of  the  constitutional  disorder,  in  some 
instances,  after  the  sloughs  are  cast,  effusion  of  lymph  and  granu- 
lation may  take  place,  and,  unless  much  care  is  taken  in  dressing, 
great  part  of  the  vaginal  orifice  and  the  labia  are  united  perma- 
nently, leaving  only  a small  orifice  for  the  escape  of  the  urine.  In 
this  manner  the  vagina  is  not  unfrequently  closed  so  as  to  simulate 
congenital  imperforation.  It  appears  from  the  account  of  Mr 
W ood,  that  this  inflammation  is  confined  chiefly  to  the  labia,  the 
nymphcB,  the  clitoris,  and  hymen  ; and  it  does  not  seem  to  affect 
the  vagina. 

In  a medico-legal  point  of  view  it  is  important  to  distinguish 
this  disease  from  the  effects  of  violation,  with  which  it  has  been 
confounded. 


III.  Haemorrhage. — In  the  mucous  membranes  hemorrhage  is 
frequent ; and  though  none  of  them  can  be  said  to  be  exempt  from 
it,  it  is  most  common  in  the  Schneiderian  or  nasal  membrane,  in  the 
pulmonic,  intestinal,  and  uterine  mucous  surfaces.  In  the  hemor- 
rhagic form  of  land-scurvy,  {purpura  hasmorrhagica'),  with  the 
bloody  spots  on  the  outer  surface  of  the  corion  of  simple  purpura, 
are  combined  spots  and  hemorrhage  from  almost  all  the  mucous 
surfaces.  Of  the  hemorrhages  of  the  mucous  membranes  the  fol- 
lowing table  may  be  given: — 


Nasal  passages, 
Mouth, 

Bronchial  membrane, 
Stomach, 

Ileum  and  colon. 
Rectum, 

Bladder, 

Urethra, 

Womb, 


Epistaxis. 

Stomacace, 

Hcemoptysis, 

Haimatemesis, 

Meloena;  DysenUnj, 

Hcemorrhois, 

Hcematuria, 


Pneumonorvhajia. 

Gastrorrhagia. 

Enierorrhagia. 

Pi'octorrhagia. 

Cystirrhagia. 

UrethrorrJiagia. 

Menorrhagia. 


In  these  several  regions  of  the  mucous  surfaces,  the  pathology 
of  hemorrhage,  which  has  been  already  partially  considered,  is 
much  the  same.  The  discharge  of  blood  or  bloody  fluid  from  any 
of  the  mucous  membranes  is  not  so  much  a disease  of  itself  as  one 
of  the  eflPects  of  some  degree  or  variety  of  the  inflammatory  process. 
Thus  blood  is  discharged  from  the  bronchial  membrane  during 
bronchial  inflammation ; from  the  gastric  mucous  membrane  dur- 


History  of  a very  fatal  aft'ection  of  the  pudenda  of  female  children,  by  Kinder 
M ood,  Esq.  jVlecl.-Chir.  Trans.  V'ol.  vii.  p.  o5,  Ac. 


664 


GENERAL  AND  RATHOLUGICAL  ANATOMY, 


ing  vascular  congestion  of  the  stomach;  from  the  intestinal  during 
the  congestion  of  dysentery ; and  from  that  of  the  rectum  during 
the  vascular  state  attendant  on  hemorrhois.  In  these  circumstances, 
the  hlood,  whether  pure  or  mingled,  as  it  often  is  with  mucous,  mu- 
co-purulent  or  puriform  fluid,  oozes  from  the  mucous  membranes 
without  destruction  of  tissue,  or  rupture  of  vessels,  or,  in  the  lan- 
guage of  the  physiologist,  is  exhaled.  ‘‘  I have  often  opened,”  says 
Bichat,  “ persons  who  have  died  during  hemorrhage,  and  have  ex- 
amined the  bronchial,  gastric,  intestinal,  and  uterine  surfaces,  yet 
have  not  perceived  the  slightest  trace  of  erosion,  notwithstanding 
the  precaution  of  washing  ihem  with  care,  allowing  them  to  mace- 
rate, and  afterwards  submitting  them  to  examination  by  means  of 
a lens.”*  In  this  manner,  therefore,  are  to  be  explained  those 
slight  hemorrhages  which  take  place  in  pulmonary  catarrh  {hcemop- 
toe),  about  the  termination  of  peripneumony,  and  in  young  females 
after  the  accidental  suppression  of  the  menstrual  discharge. 

From  these  the  more  copious  and  irresistible  hemorrhages  from 
mucous  surfaces  differ  chiefly  in  a previous  serious  lesion  of  the  mu- 
cous or  submucous  tissue.  This  lesion  consists  in  vascular  injec- 
tion more  or  less  extensive  of  the  mucous  corion,  and  injection  oc- 
casionally very  complete,  and  amounting  to  extravasation,  of  the 
submucous  tissue,  which  is  thus  rendered  red-brown,  hard,  and 
void  of  its  natural  elasticity.  Of  the  former  instances  are  seen  in 
the  gastro- enteric  mucous  membrane  during  luEmatemesis^  melcBna, 
and  bloody  flux ; and  the  latter  may  be  observed  in  the  lungs  du- 
ring limmoptysis,  and  in  the  rectum  in  hcemorrhois.  These  princi- 
ples are  so  well  established  by  numerous  facts,  that  it  is  unneces- 
sary to  strengthen  them  by  any  elaborate  induction.  I shall  mere- 
ly adduce  the  phenomena  of  a few  of  the  hemorrhagic  diseases  in 
illustration  of  the  general  doctrine  that  hemorrhage  is  an  exhala-^ 
tion  from  parts,  the  capillaries  of  which  are  previously  inordinately 
distended. 

§ 1.  The  G astro-enteric  Membrane.  Hcematemesis  and  Melcena. 
— On  the  pathology  of  this  disorder,  so  much  misunderstood  by  the 
ancients,  it  is  unnecessary  to  dwell.  Correct  views  were  first  given 
by  Hoffmann,  who,  from  the  fact  of  finding  in  dead  bodies  the  me- 
senteric vessels  and  those  of  the  ileum  much  distended  with  black 
blood,  and  the  stomach  filled  with  the  same,  taught  that  the  bloody 
discharge,  whether  from  the  upper  or  the  lower  end  of  the  canal, 
proceeds  not  immediately  from  the  vessels  of  the  stomach,  or  from 

* Anatomie  Generale,  Tome  i.  p.  5b'3,  565. 


MUCOUS  MEMBRANE. 


665 


blood  extravasated  into  its  cavity,  but  also  from  the  vessels  of  the 
small  intestines,  especially  those  of  the  ileum.*  This  inference  is 
confirmed  by  several  dissections  of  Valsalva  and  Morgagni,!  who 
in  hsematemesis  and  intestinal  hemorrhage  found  the  gastro-enteric 
mucous  membrane  always  entire,  and  its  vessels  more  or  less  in- 
jected. 

From  an  extensive  collection  of  cases,  Portal  derives  conclusions 
still  more  distinct.  This  anatomist  shows,  Is?,  that  the  black  mat- 
ter discharged  by  vomit  and  by  stool,  or  by  vomiting  only,  is  ge- 
nuine blood,  which  is  seen  to  ooze  after  death  from  the  blood-ves- 
sels of  the  stomach  and  intestines ; 2d,  that  this  oozing  or  trans- 
udation takes  place  from  the  gastric,  duodenal,  and  mesenteric  ar- 
terial extremities  into  the  cavity  of  the  stomach  or  intestines,  sepa- 
rately or  at  once,  more  frequently  into  the  stomach  only,  in  conse- 
quence of  certain  arterial  branches  receiving  more  blood  than  the 
corresponding  veins  return  ; and,  2>dly,  though  compression  of  the 
branches  of  the  portal  vein  may  cause  this  extravasation,  the  blood 
is  not  eflfused  from  the  vasa  brevia,  in  which  it  flows  in  an  opposite 
direction.! 

Similar  are  the  views  of  Abernethy,  who  states  that  in  the  bodies 
of  several  persons  who  died  under  attacks  of  this  disease,  he  found 
‘‘  the  villous  coat  of  the  alimentary  canal  highly  inflamed^  sioollen, 
and  pulpy.  Bloody  specks  were  observed  in  various  parts ; and 
sphacelation  had  actually  taken  place  in  one  instance.  The  liver 
was  healthy  in  some  cases  and  diseased  in  others.”  He  concludes, 
therefore,  that  the  diseases  termed  hcBmatemesis  and  melmia  arise 
from  “ violent  disorder,  and  consequent  diseased  secretion  of  the 
internal  coat  of  the  bowels ; and  that  the  blood  discharged  does 
not  flow  from  any  single  vessel,  but  from  the  various  points  of  the 
diseased  surface. ”§  From  the  same  source  originates  the  cocoa- 
coloured  fluid  observed  by  Baillie  in  fatal  cases  of  h(Bmatemesis.\\ 

It  may  therefore  be  inferred,  that  the  blood  discharged  in  this 
disease  issues  from  the  loaded  capillary  vessels  of  the  gastric,  duo- 
denal, and  ileal  mucous  membrane  without  breach  of  stu-face  ; and 
as  it  is  anatomically  impossible  to  distinguish  these  vessels  into  ar- 

* Medicin®  Rationalis  Systematic®,  pars  ii.  sect.  i.  chap.  Hi.  § 17. 

Epist.  xxix.  10  ; xxxi.  23  ; xxxvi.  11. 

+ Memoires  sur  la  Nature  et  le  Traitement  de  Phisieurs  Maladies,  Par  Antoine 
Portal,  Tom.  ii.  Paris,  1800.  P.108. 

§ On  the  Constitutional  Origin  and  Treatment,  &c.  p.  30.  London,  1811. 

II  Lectures  and  Observations  on  Medicine. 

3 


666 


GENERAL  AND  PATUOLOGICAL  ANATOMY. 


teries  and  veins,  the  dispute  whether  the  blood  issues  from  the  one 
or  other  order  is  fi’ivolous.  The  blood  may  acquire  its  dark  colour 
from  two  causes;  1st,  admixture  with  the  gastric  juice  in  the  sto- 
mach and  duodenum ; and  2d,  from  the  action  of  the  carbonic  acid, 
sulphuretted  hydrogen,  and  other  substances  of  acid  properties  con- 
tained in  the  intestinal  canal. 

§2.  Hcemoptysis ; Pneumonorrhagia  ; Pulmonary  Hemorrhage ; 
Pulmonary  Apoplexy. — For  the  first  accurate  description  of  the 
anatomical  characters  of  pulmonary  hemorrhage,  we  are  indebted 
to  the  researches  of  the  elaborate  Stark,  who  ascertained  the  fol- 
lowing facts.  The  air  vesicles  in  some  parts  of  the  lungs  are  filled 
with  blood  or  bloody  serum ; the  parts  do  not  collapse  on  opening 
the  chest,  but  are  firm,  dark  or  light  red  in  colour,  and  can  neither 
be  compressed  nor  distended  by  the  usual  inflation.  When  cut 
into,  thick  blood  or  bloody  matter  issues  from  the  cut  surfaces ; 
and  portions  of  the  diseased  parts,  after  being  macerated  in  water, 
still  sink  as  before  maceration.  He  further  showed,  by  blowing 
air  into  the  blood-vessels  and  air-tubes  of  the  sound  and  diseased 
portions  respectively,  that  in  the  latter  air  passes  from  the  branches 
of  the  pulmonary  artery  and  veins  into  the  bronchial  tubes ; in 
other  words,  that  the  capillary  vessels  of  the  lungs  communicate 
freely  with  the  bronchial  tubes  and  air-cells.* 

The  general  accuracy  of  this  desciiption  has  since  been  verified 
by  the  researches  of  Laennec,  who  has  indeed  rendered  the  patho- 
logical anatomy  of  this  disease  more  precise  than  formerly.  From 
these,  it  results  that  a portion  of  the  pulmonic  tissue  becomes  uni- 
formly hard,  of  a dark  red  colour,  and  impermeable  to  air.  The 
indurated  spot  is  always  partial,  from  one  to  four  cubic  inches  in 
extent,  circumscribed  with  sound  or  pale-coloured  lung,  and  looks 
not  unlike  a clot  of  venous  blood ; circumstances  by  which  it  is  to 
be  distinguished  from  pneumonic  induration,  which  terminates  gra- 
dually in  sound  lung.j  These  changes,  which  consist  in  extreme 
injection  of  the  pulmonic  capillaries,  and  in  effusion  of  blood  into 
the  submucous  filamentous  tissue,  and  into  the  pulmonic  vesicles, 
are  confined,  however,  chiefly  to  the  severe  forms  of  pulmonary  he- 
morrhage. They  are  the  effects  of  previous  injection  of  the  capil- 
laries, which  is  to  be  considered  as  the  uniform  cause  of  hemor- 
rhage. 

* The  Works  of  the  late  William  Stark,  M.  D.  Ac.  London,  1788,  p.  3L 

f Traite  de  I’Auscultation  Mediate,  &c. 


MUCOUS  MEMBEANE. 


667 


Much  the  same  changes  are  observed  in  the  rectum  and  its  sub- 
mucous tissue  in  hemorrhoidal  disease.  This  is  proved  by  the  tes- 
timony of  Latta,*  Benjamin  Bell,f  Callisen,+  Monteggia,§  Del- 
pech,ll  Chaussier,  Larroque,  and  Calvert. H This  disorder  is  to 
be  distinguished  from  varix  of  the  veins  of  the  bovpels. 

I conclude  this  subject  with  a few  remarks  on  hemorrhage  from 
the  uterine  mucous  membrane  in  the  state  of  impregnation.  It  is 
generally  supposed  that  hemorrhage  taking  place'at  this  period  is 
the  effect  of  abortion  ; and  Denman  and  some  other  authors  em- 
ploy a good  deal  of  not  very  intelligible  argument  to  prove  the 
proposition.  It  may,  however,  be  demonstrated,  that  hemorrhage, 
or,  to  speak  more  to  the  fact,  the  abnormal  state  of  the  uterine  ca- 
pillaries, which  leads  to  hemorrhage,  is  the  cause  of  abortion  ; and 
that  almost  no  instance  of  abortion  takes  place  without  previous 
hemorrhagic  distension  of  the  uterine  or  utero-placental  capillaries. 
By  Denman  himself  it  is  remarked,  that  “ when  abortion  is  about 
to  happen,  there  is  usually  between  this  (the  decidua  rejlexa)  and 
the  outer  membrane  of  the  ovum,  an  effusion  of  blood,  which  often 
insinuates  itself  through  the  cellular  membrane  of  the  placenta,  and 
between  the  membranes,  giving  externally  to  the  whole  ovum  a tu- 
mid and  unequal  appearance,  not  unlike  a lump  of  coagulated 
blood,  for  which  it  has  been  frequently  mistaken,  and  then  it  is 
popularly  called  a false  conception.”**  I have  had  occasion  to  ob- 
serve the  phenomena  of  sevei'al  abortions  with  some  care ; and  in 
every  one  I have  traced  them  to  some  degree  of  hemorrhage  taking 
place  from  the  uterine  or  utero-placental  vessels.  The  blood  which 
Denman  remarks  is  found  insinuated  through  the  cellular  mem- 
brane of  the  placenta  is  derived  from  the  vessels  of  that  body.  It 
is  not,  therefore,  the  premature  effort  of  the  uterus  to  contract  that 
constitutes  abortion ; but  the  inordinate  distension  of  its  vessels, 
which  terminates  in  hemorrhage,  and  the  occurrence  of  which  then 
excites  the  uterus  to  premature  contraction.  The  vessels  of  the 
uterus  and  placenta,  naturally  full  of  blood,  may,  from  a variety 
of  causes  operating  on  the  mother,  become  unusually  distended, 

* A Practical  System  of  Surgery,  Vol.  ii.  Chap.  iv.  p.  34. 
f A System  of  Surgery,  Vol.  vi.,  7.  Edit.  Chap.  xxiv.  p.  324. 
t Systema  Chii-urgise  Hodiernise,  Vol.  ii.  Edit.  4to.  p.  12b'. 

§ Tnstituzione  Chirurgiche,  Vol.  viii.  Chap.  xv.  389. 

II  Precis  Elementaire,  &c.  Tome  iiime.  Sect.  viii.  Chap.  I,  § ii.  p.  262. 

'll  A Practical  Treatise  on  Hemorrhoids,  &c.  London,  1824.  P.23,24. 

**  Principles  of  Midwifery,  V ol.  ii.  p.  280. 


668 


GENEIUL  AJMI)  PATHOLOGICAL  ANATOMY. 


and  discharge  blood  as  in  other  hemorrhagic  injections.  This  exu- 
dation taking  place  either  at  the  uterine  surface,  or  in  the  substance 
of  the  placenta,  or  in  both  at  once,  speedily  detaches  the  placenta 
from  the  womb ; the  usual  supply  of  blood  is  interrupted  ; and  the 
foetus  perishes  in  consequence.  In  this  sense  only  can  the  remark 
of  Leake  be  well-founded.  “ Whatever  may  be  tbe  cause  of  abor- 
tion, the  effect  is  produced  by  a separation  of  the  after-burden  from 
the  womb,  and  consequently,  the  child,  being  deprived  of  nourish- 
ment, must  soon  perish  and  be  expelled.”*  The  difficulty  here  re- 
fers to  the  remote  causes,  which  may  be  different  in  different  cases. 
The  pathological  cause  is  invariably  the  same. 

Febrile  yastro-enteric  hemorrhage. — That  the  black  or  coffee- 
ground  vomit,  {vomito  prieto,')  and  dark-coloured,  tar- like,  or  mo- 
lasses-like stools,  which  take  place  in  bad  remittents,  malignant 
agues,  and  yellow  fever,  consist  in  hemorrhage  from  gastro- enteric 
mucous  membrane,  is  established  by  the  researches  of  Physick,  Dr 
John  Hunter,  Bancroft,  Jackson,  and  many  other  authors.  In  all 
cases  in  which  subjects  dead  of  these  diseases,  under  these  symp- 
toms, have  been  inspected,  the  same  kind  of  coffee-ground  matter 
has  been  found  in  the  stomach  and  intestines,  but  without  breach 
of  the  mucous  surface.  The  matter,  however,  has  been  traced 
almost  in  its  formation,  in  the  circumstance  of  dark  blood  oozing 
insensibly  from  the  capillaries  of  the  mucous  membrane.  Its  co- 
lour is  necessarily  rendered  more  intense  by  the  fluids  of  the  gas- 
tro-enteric  surface.  This  peculiar  exudation  may  be  regarded  as 
the  result  of  disorganization  of  the  mucous  capillaries,  in  conse- 
quence of  previous  congestion  during  the  febrile  action.  Not  con- 
fined, however,  to  the  gastro-enteric  mucous  surface,  it  occurs  in 
the  tracheo-bronchial  and  genito-urinary.  It  is  observed  also  oc- 
sionally  in  other  tissues  from  the  same  cause.  In  short,  febrile 
action  either  consists  in,  or  is  the  cause  of  capillary  disorganization 
in  most  of  the  textures. 

The  process  of  hemorrhagic  injection,  like  that  of  inflammation,' 
may  terminate  in  suppuration,  with  or  without  breach  of  surface, 
in  induration,  and  thickening,  dependent  on  chronic  inflammation. 


IV.  Inflammatory  Stricture. — To  thickening  as  an  eflPect  of 
the  inflammatory  process,  I have  already  had  frequent  occasion  to- 
allude.  This  takes  place  to  a small  extent  in  the  mucous  corion, 
and  to  a much  greater  degree  in  the  submucous  filamentous  tissue, 

* V'ol.  i.  p.  119. 


MUCOUS  MEMBRANE. 


669 


in  which  it  depends  partly  on  the  increased  number  of  vessels, 
partly  on  the  effusion  of  lymph,  which  causes  the  mutual  cohesion 
of  its  component  filaments.  When  this  is  considerable,  and  takes 
place  in  a membrane  lining  a canal,  it  contracts  its  capacity,  and 
forms  what  is  named  stricture  ; {constrictio)  •,  {arctatio.')  Though 
this  may  occur  in  any  part  of  the  mucous  system,  it  is  most  com- 
mon in  the  lacrymal  canal,  the  Eustachian  tube,  the  oesophagus, 
near  its  upper  or  lower  extremity,  the  rectum  or  lower  part  of  the 
colon,  and  in  the  male  urethra.  The  constriction,  in  such  circum- 
stances, depends  not  unfrequently  on  the  presence  of  some  remain- 
ing degree  of  inflammation ; and  if  this  subside,  the  constriction 
may  also  partially  diminish.* * * §  To  its  entire  disappearance,  how- 
ever, the  absorption  of  the  effused  lymph  is  essentially  necessary  ; 
and  in  all  probability  this  is  never  completely  effected.  In  the  in- 
testinal canal  especially,  this  induration  may  be  so  great  that  the 
tissue  of  the  tube  becomes  hard  and  firm  like  parchment  or  carti- 
lage, and  at  the  same  time  much  thicker  than  natural.  The  calibre 
of  the  canal  then  becomes  so  much  contracted  that  nothing  passes 
through  it ; and  life  is  terminated,  partly  by  inanition  and  deficient 
nutrition,  partly  by  irritation.  I have  already  alluded  to  partial 
contractions  recorded  by  various  authors,  from  Haase,  Wincker, 
and  Laubius,  to  Dr  Combe  and  Willan.  The  most  perfect  ex- 
ample of  total  contraction  with  which  I am  acquainted  is  recorded 
by  M.  Tartra  in  his  Essay  on  Poisoning  by  Nitric  Acid.  In  an 
individual  who  died  three  months  after  swallowing  this  poison,  the 
alimentary  canal  was  reduced  to  so  small  volume,  that  it  might 
have  been  held  in  the  hollow  of  the  hand.  Its  coats  were  shrivel- 
led, crisp,  and  indurated ; and  its  calibre  through  its  whole  length 
did  not  exceed  that  of  a common  quill. | Under  such  circumstances, 
all  the  intestinal  tissues  suffer  successively  and  simultaneously  the 
efiects  of  the  inflammatory  process ; and  the  contraction  is  aug- 
mented by  the  violent  and  excessive  stimulus  which  it  applies  to  the 
muscular  layer. 

That  a similar  change  takes  place  in  the  mucous  and  submucous 
tissues  of  the  bladder  is  shown  by  the  observations  of  Guarinonius, 
Bonetus,  Camerarius,  Targioni,  Morgagni,|  Dr  Barry,§  Dr  Gil- 

* Home.  Howship,  Practical  Observations,  p.  254. 

t Essai  sur  I’empoissonnement,  &c. 

Epist.  iv.  13,  19.  X.  i3.  xxii.  4.  xxxix.  33.  xl.  22.  xli.  13.  xlii.  20,  33,  34.  xliii.  24. 
xliv.  15.  xlviii.  32.  xlix.  18. 

§ Edinburgh  Med.  Essays,  Vol.  i.  p.  266. 


070 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Christ,*  Dessault,t  Baillie,f  Fr.  Aug.  Walter, § Charles  Bell,|| 
Forster, H and  other  authors,  who  found  the  mucous  coat  thicken- 
ed and  indurated  like  cartilage,  and  the  cavity  much  contracted. 
It  is  at  the  same  time  generally  sacculated. 

Another  form  of  inflammatory  thickening,  causing  diminished 
area  of  mucous  canals,  is  that  which  takes  place  in  chronic  en- 
largement of  the  mucous  glands.  The  best  example  of  this  is  ob- 
served in  the  enlargement  of  the  raucous  follicles  of  the  cardia, 
which  is  no  uncommon  cause  of  stricture  of  the  cardiac  orifice  of 
the  oesophagus.  This  inflammation  is  very  difficult  of  resolution, 
and  too  often  terminates  in  ulceration  of  the  membrane  and  the 
glands. 

4.  Adhesion. — It  was  asserted  by  Bichat  and  others,  that  mucous 
membrane  does  not  effuse  lymph  or  contract  adhesions.  The  ac- 
curacy of  this  conclusion,  which  evidently  arose  from  opinions  too 
generalized  on  the  properties  of  this  tissue,  the  nature  of  lymph, 
and  the  final  causes  or  rather  purposes  of  morbid  action,  is  ques- 
tionable, and  the  inference  requires  limitation.  Independent  of 
the  well  known  experiment  of  John  Hunter,  who,  by  the  use  of  a 
very  irritating  injection,  produced  a secretion  of  coagulable  lymph 
in  the  vagina  of  an  ass ; — I have  already  shown  that  each  of  the 
mucous  surfaces,  under  certain  states  and  forms  of  inflammatory 
action,  may  effuse  a fluid  containing  a large  proportion  of  albumen, 
and  which,  neither  in  chemical  properties  nor  pathological  relations, 
can  be  distinguished  from  the  albuminous  exudation  of  serous 
membranes.  The  question  of  adhesion,  however,  depends  not  s 


much  upon  the  fact  of  albuminous  exudation  as  upon  the  anatc 


mical  disposition  of  the  cavity  or  canal,  whether  it  be  sufficient! 
small  to  favour  the  mutual  approximation  of  opposite  and  cona 
spending  surfaces.  Thus  in  the  gastro-intestinal  membrane,  whic 
is  in  general  capacious  and  distended,  either  incessantly  or  fn 
quently  with  foreign  bodies,  mutual  approximation  is  too  imperfei 
to  admit  of  adhesion.  Yet  by  some  observers  this  is  asserted  t 
have  happened.  In  situations,  on  the  contrary,  in  which  mucoi 
surfaces  line  narrow  tubes,  as  the  lacrymal  duct,  the  Eustachia 
tube,  the  urethra,  and  perhaps  the  Fallopian  tubes,  obliteration  c. 
the  canal  by  adhesion  of  its  sides  is  more  frequent.  It  is  certain 

* Essays,  Physical  and  Literary,  Vol.  iii.  -j-  Journal  de  Chirurgie. 

t Engravings,  &c.  7th  Fascicul.  pi.  I.  fig.  2d. 

§ Einige  Krankheiten  der  Nieren  und  Harnblase,  u.  s.  w.  p.  31.  Tafel.  ix. 

II  Engravings,  &c.  Med.-Chir.  Trans.  Vol.  i.  art.  9. 


]\rUCOUS  JIEMBRANE. 


671 


that  the  surgeon  has  not  unfrequently  occasion  to  observe  corre- 
sponding points  of  narrow  canals,  as  the  urethra,  adhering  appa- 
rently by  concretion  of  its  sides.*  I have  had  occasion  to  ad- 
vert above  to  a mode  in  wbicb  the  vaginal  mucous  membrane  may 
contract  adhesions,  and  present  the  similitude  of  congenital  imper- 
foration.  The  assertion  of  Bichat  regarding  the  inaptitude  of  mu- 
cous surfaces  to  adhere  requires,  therefore,  some  limitation.  Cer- 
tain facts  lead  me  to  infer  that  one  of  the  conditions  necessary  to 
the  albuminous  exudation  and  the  subsequent  concretion  of  mutual 
surfaces  consists  in  the  destruction  of  the  mucous  epidermis  by 
abrasion  or  ulceration,  and  the  subsequent  formation  of  granula- 
tions, which  in  the  course  of  healing  unite  the  opposite  edges  of 
the  canal. 

V.  Induration  and  thickening  ; Cartilaginous  transfor- 
mation OF  MUCOUS  MEMBRANE  AND  CANALS.  ChONDROSIS. 
Hypertrophy. — It  is  not  easy  to  say  to  what  head  the  change  here 
adverted  to  should  be  referred.  For  it  is  not  by  any  means  easy  to 
determine  its  exact  nature ; or  even  whether  it  be  an  affection  of 
the  mucous  membrane  solely,  or  of  tbe  muscular  structure,  or  of 
both  taken  together.  My  chief  reason  for  referring  it  to  the  pre- 
sent head  is  because  there  is  a very  considerable  affection  of  the 
mucous  membrane,  at  its  free  surface. 

The  lesion  consists  in  the  conversion  of  a portion  of  mucous  mem- 
brane and  its  subjacent  tissue,  generally  muscular  or  fibrous,  into 
a thick,  bard,  cartilaginous  substance,  sometimes  with  contraction 
of  the  canal,  sometimes  with  dilatation.  The  mucous  surface  is 
irregular,  honey-combed  as  it  were,  and  rough,  with  numerous  in- 
tersecting ridges,  fii’m  and  generally  of  a whitish  gray  colour. 

It  is  liable  to  affect  the  mucous  membrane  of  the  oesophagus, 
and  forms  there  one  species  of  stricture ; the  mucous  membrane  of 
the  where  it  also  forms  a species  of  stricture  ; and  the  mucous 

membrane  of  the  colon,  where  in  like  manner  it  generally  causes 
arctation  of  the  calibre  of  the  canal. 

The  region,  however,  in  which  this  lesion  is  most  distinctly  seen, 
and  proceeds  to  its  greatest  extent,  is  that  of  the  ureters  and  bladder. 
Tbe  former  canals  become  thick  to  the  diameter  of  half  an  inch  and 
more,  their  coats  are  hard,  firm,  of  cartilaginous  consistence,  and  a 
gray-white  colour ; the  internal  of  mucous  surface  is  rough  and 

* Smith  Ward,  Mem.  Med.  Society,  Vol.  iii.  p.  .536.  Maclurc,  Med.  and  Surg. 
Journal. 


672 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


honey-comb  like,  with  innumerable  intersecting  lines ; and  the  canal 
of  the  ureters  may  be  either  natural,  contracted,  or  dilated. 

The  bladder  is  always  much  contracted.  Its  coats  are  thickened 
either  to  the  extent  of  that  of  the  ureters  or  more ; from  half  an 
inch  to  three  quarters.  The  thickening  is  seated  both  in  the  mucous 
membrane  and  in  the  muscular  coat,  but  often  more  in  the  former 
than  in  the  latter.  The  surface  is,  like  that  of  the  ureteric  mem- 
brane, irregular  and  honeycomb-like.  The  substance  of  the  mucous 
coat  is  as  firm  as  cartilage ; and  the  same  transformation  appears  to 
affect  the  muscular  coat.  Occasionally  the  bladder  is  sacculated. 

The  causes  and  exact  nature  of  this  change  are  not  well  known. 

It  seems  like  a species  of  hypertrophy ; and  from  this,  nevertheless, 
it  differs.  The  instances  which  have  fallen  under  my  own  notice 
occurred  in  persons  under  35.  But  I daresay  that  it  may  appear 
in  old  age. 

VI.  Morbid  Growths. — § 1.  Polypus. — Under  this  name  va-^ 
rious  morbid  growths  are  mentioned  by  authors.  It  is  represented  as  ^ 
a disease  peculiar  to  the  mucous  tissue,  and  is  generally  observed 
to  take  place  in  those  regions  at  which  it  is  not  very  remote  from"|jJ 
the  skin.  It  occurs  particularly  in  the  nose,  throat,  Eustachian® 
tube,  the  external  earhole,  and  in  the  neck  of  the  womb.  In  the® 
stomach  and  bladder  it  is  less  frequent,  and  it  very  rarely  occurs  ® 
in  the  intestinal  tube.  It  appears  under  one  of  three  forms.  w 

1.  It  may  take  place  in  the  form  of  a soft  ash-gray  or  bluish  pro-  ^ 
duction,  glistening  on  the  surface,  translucent,  spongy,  and  com- 
pressible,  and  attached  to  the  membrane  by  one  or  more  narrow  || 
necks,  which  render  it  pendulous.  This,  which  is  what  is  termed  V 
by  practical  authors  the  benign  polypus.^  is  proper  to  the  mucous  fj 
tissue,  of  which  it  appears  often  to  be  merely  a relaxed  production  x| 
or  growth.  It  is  much  under  the  influence  of  atmospheric  pressure,  S 
increasing  in  size,  and  causing  much  uneasiness  while  the  weather  I 
is  moist  and  the  mercurial  column  is  low.  In  clear  dry  weather,  on  ^1  i 
the  contrary,  and  when  the  height  of  the  barometer  indicates  vigo-  1 
rous  atmospheric  pressure,  it  shrinks  and  contracts  so  much  that  the  | ' 
patient  seems  to  forget  its  existence.  This  form  of  polypus  is  fre- 
quent in  the  nasal  mucous  membrane,  in  which  it  causes  much  ] | 
uneasiness  during  its  distended  state.  It  may  grow  also  from  the  I 
fibro-mucous  membrane  of  the  frontal,  sphenoidal,  and  maxillary 
sinuses.*  When  removed  it  presents,  with  a few  blood-vessels,  a 

• G.  F.  Gruner  de  Polypis  in  cavo  Navium  obviis.  I 


MUCOUS  MEMBRANE. 


073 


flocculent  tomentose  structure,  which  is  well  seen  by  immersion  in 
water,  in  which  it  generally  floats.  It  occurs  also  in  the  throat ; 
and  polypi  of  the  same  description  I have  removed  from  the 
external  auditory  hole.  Ruysch  observed  them  growing  in  the 
maxillary  sinus,  and  proceeding  through  the  passage  below  the 
spongy  bone  into  the  nostril, — a fact  which  I find  verified  by  an 
observation  of  M.  Giles.*  The  same  sort  of  tumour  is  occasionally 
found  in  the  vagina  ; and  it  is  a remarkable  proof  of  the  general 
tendency  to  the  formation  of  these  productions,  that  in  some  indi- 
viduals I have  seen  them  occur  at  the  same  time  in  the  nasal  and 
vaginal  mucous  membrane.  The  formation  of  this  variety  of  polypus 
is  ascribed  by  Morgagni  to  abnormal  development  of  the  mucous 
glands  ;t  a theory  in  which  he  is  followed  by  Plenck.|  This,  how- 
ever, is  too  exclusive,  and  is  not  applicable  to  all  cases. 

2.  The  name  of  polypus  is  also  given  to  a firm  fleshy  incompres- 
sible mass,  oval,  spheroidal  or  pyriform,  opaque,  dark  red  or  purple 
in  colour,  sometimes  with  narrow,  sometimes  with  broad  and  rnul- 
tifid  basis.  This  form  of  polypus,  which  is  not  influenced  by  the 
weather,  is  observed  to  occur  in  the  pharyngeal  or  oesophageal  mu- 
cous membrane,  (Monro) , in  that  of  the  stomach,  (Morgagni,§ 
Monro,ll  Granville  ;1T)  in  the  intestines,  in  the  colon,  and  rectum, 
(Rhodius,  Fanton,  Portal,  hlonro.)  In  the  case  of  M.  Paulo,  re- 
corded by  Portal,  two  fleshy  concretions  as  large  as  the  fist  were 
voided  during  life ; and  after  death,  which  was  preceded  by  hectic 
and  wasting,  in  the  ascending  and  transverse  colon  were  found  four 
polypous  tumours,  each  as  large  as  a nut,  and  two  smaller  ones  at- 
tached to  the  mucous  membrane.**  A good  example  of  polypus 
of  the  rectum  is  recorded  by  Dr  Monro,  tertius.'\\  In  the  bladder 
they  are  mentioned  by  Warner,  Baillie,  and  Walter.  Instances  of 
uterine  polypus,  (cercosis,  Plenck,)  are  recorded  by  Mauriceau, 
Lamotte,  Morgagni,  Lieutaud,  Levret,  Sabatier,  Baudelocque, 
Denman,  and  Clarke.  From  these  it  results,  that  though  polypus 
occasionally  originates  from  the  mucous  membrane  of  the  fundus, 
it  more  frequently  grows  from  the  inside  of  the  neck,  or  from  the 
os  tmcce  itself.  Upon  the  nature  or  the  mode  of  development  of 
this  variety  of  polypus  nothing  satisfactory  is  known.  It  appears  to 

* Phil.  Trans.  No.  226,  p.  472.  t Epist.  xvi.  36. 

$ “ Causa  polypi  proxima  est  papill®  pituitariae  excrescentia  seu  yegetatio  mor- 
bosa.”  Systeraa  Tumorum,  Classisiii.  p.  173. 

§ Epist.  xiv.  17,  18.  II  Morbid  Anatomy,  p.  189,  pi.  vi. 

^ Med.  Rep.  Aug.  1817.  **  Anatomie  Medicale,  Tome  v.  p.  213. 

-ff  Morbid  Anatomy  of  the  Gullet,  p.  192. 


U U 


674 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


consist  in  deposition  of  matter  entirely  new,  either  in  the  mucous  j| 
corion,  or  in  the  submucous  filamentous  tissue.  The  tumour  is  j 
almost  invariably  covered  by  a thin  pelliele  similar  to  mucous 
membrane,  but  much  more  vascular.  It  appears,  on  the  whole,  to 
be  much  of  the  nature  of  vascular  sarcoma  occurring  in  other  tex-  | 
tures.  It  is  generally  vascular,  often  traversed  by  varicose  veins,  | 
is  liable  to  frequent  hemorrhage,  and  occasionally  degenerates  into 
destructive  ulceration.  It  ought  not,  however,  to  be  confounded 
with  cancer. 

3.  The  name  of  polypus  is  also  given  to  a broad,  sometimes  flat, 
hard  tumour,  taking  place  in  the  nasal  mucous  membrane,  and  pe- 
culiar apparently  to  this  region.  It  is  generally  of  a reddish  or 
brown  colour,  harder  even  than  the  fleshy  polypus,  smooth  on  the  5 
surface,  and  presenting  the  appearance  of  mucous  membrane.  | 
From  several  examples  of  this  disease  which  I have  had  an  oppor- 
tunity of  examining,  I infer  that  it  depends  on  some  abnormal  de-  t 
velopment  of  the  fibro-mucous  covering  of  the  spongy  or  nasal  ! 
bones.  It  affects  not  the  mucous  membrane  only,  but  the  subja- 
cent periosteum,  and  adheres  firmly  to  the  bones,  fragments  of  i; 
which  are  not  unfrequently  rent  off  in  the  attempt  to  extract  this  i 
polypus.  It  has  a tendency  to  induce  inflammation  and  caries  of  | 
the  bones,  but  does  not  appear  to  possess  much  malignant  tendency 
of  itself.  Upon  the  whole,  this  variety,  though  commonly  deno- 
minated polypus,  is  in  truth  a tumour  of  the  periosteum,  partaking 
of  the  polypous  character. 

§ 2.  Tyromatous  deposition,  commonly  denominated  tubercular,  | 
is  not  uncommon  in  the  mucous  tissue.  It  occurs  chiefly  in  the 
alimentary  canal,  and  in  the  uterus  in  the  persons  of  the  strumous. 

Its  characters  in  the  former  situation  are  well  described  by  Dr 
Monro  tertius*  and  have  been  already  considered  at  length  under 
their  proper  head.  In  the  uterus  it  has  been  observed  by  several. 

§ 3.  Scirrho-carcinoma  is  a frequent  organic  change  in  mucous 
tissue.  It  occurs  under  four  forms, — fibro-cartilaginous  deposi- 
tion, tubercular  deposition,  colloid  deposition,  and  lardaceous  de-  1 
generation. 

a.  Though  fibro-eartilaginous  deposition  may  affect  any  of  the  re-  j 
gions  of  these  surfaces,  it  is  more  frequent  in  certain  points  than  in 
others.  Thus  it  occurs  very  often  in  the  oesophagus,  in  the  cardia,  in 
the  pyloric  end  of  the  stomach,  in  the  sigmoid  flexure  of  the  colon,  in 


Morbid  Anatomy,  p.  217. 


:\IUCOUS  MEMBRANE. 


675 


the  rectum,  and  in  the  uterus,  occasionally  in  the  larynx  and  trachea. 
In  the  oesophagus  and  stomach  it  has  been  seen  by  many  observers, 
among  others,  by  Morgagni,  Bleuland,  Palletta,  Baillie,  Chardel, 
Monro,  Howship,  Armstrong;  intbe  pylorus  it  has  also  been  seen  by 
many:  (Morgagni,  Baillie,  Pinel,  Holmes,  Louis,  &c.)and  tbe  rec- 
tum is  perhaps  the  most  frequent  seat  of  scirrho-carcinoma  of  any  of 
the  internal  parts.  In  all  these  situations  the  anatomical  characters 
of  the  disease  are  much  the  same.  In  the  mucous  corion,  or  at  its 
attached  surface,  is  formed  a deposition  of  white  or  gray  fibro-car- 
tilaginous  substance,  the  fibrous  bands  running  transversely  to  the 
direction  of  the  bowel.  This  deposition  is  firm,  of  ligamentous  con- 
sistence, and  undergoes  a self- destroying  process  in  the  interior. 
In  general,  however,  the  mucous  pellicle  forming  its  free  surface 
undergoes  ulceration ; or  contraction  of  the  canal  takes  place  to 
such  an  extent  as  to  interfere  with  the  functions  of  the  organ,  and 
terminate  life. 

b.  Tubercular  induration  is  another  form  in  which  scirrhus  may 
affect  the  mucous  tissue.  A portion  becomes  occupied  by  irregu- 
lar nodulated  masses,  consisting  of  hard  spheroidal  bodies  not  un- 
like cartilage,  sometimes  softer,  like  flesh  interspersed  with  cartila- 
ginous points.  This  is  observed  in  the  oesophagus  (Bonetus,  Bleu- 
land, Palletta,  Mr  David  Hay,  &c.)  in  the  cardiac  and  pyloric  ori- 
fices of  the  stomach,  and  in  the  rectum.  In  the  latter  it  forms 
many  of  the  examples  of  scirrho-contraction  of  that  organ.  This 
affection  appears  to  consist  in  peculiar  chronic  induration  with  de- 
generation of  the  mucous  follicles,  in  situations  abounding  in  which 
it  most  usually  occurs.  It  is  observed  to  attack  very  often  the  neck 
of  the  uterus.  It  is  totally  distinct  from  the  tyromatous  deposition 
of  strumous  habits,  with  which  it  has  been  occasionally  confounded 
by  some  observers.  The  tyromatous  deposition  occurs  chiefly  in 
the  young,  and  has  been  seen  even  in  infants.  Tubercular  indu- 
ration is  a disease  of  middle  age  and  declining  years.  For  some 
judicious  observations  on  the  development  and  distinctions  of  these 
two  varieties  of  cancer,  I refer  to  the  writings  of  Bayle  and  Cru- 
veilhier,  and  a Memoir  of  Scarpa  in  his  Chirurgical  Treatises.* 

By  several  authorities,  on  the  other  hand,  it  is  maintained,  that 
the  fibro-cartilaginous  and  tubercular  scirrhus  are  the  same  in 
structure  and  characters,  and  differ  only  in  the  mode  in  which  the 
scirrhous  matter  is  deposited.  This  view  may  be  correct.  It  is 


Opuscoli  (li  Chirurgia  di  Antonio  Scarpa,  &c.  Vol.  i.  Pavia,  1825. 


676 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


perhaps  of  no  great  moment.  It  may  be  merely  observed,  that 
while  the  fibro-cartilaginous  form  of  scirrhus  is  common  in  the  ex- 
ternal glands,  as  the  mamma,  lacrymal  gland,  salivary  glands,  and 
testicle,  tubercular  scirrhus  is  usually  seen  in  the  skin  and  in 
certain  parts  of  the  mucous  membranes,  as  the  oesophagus,  cardia, 
pylorus,  and  rectum ; and,  according  to  Scarpa,  the  uterine  end 
of  the  vagina  and  the  os  uteri  itself. 

c.  Reticular,  Areolar,  Alveolar,  and  Colloid  Cancer. — A third 
form  in  which  cancer  may  attack  the  mucous  surfaces  is  that  which  is 
named  reticular  and  areolar,  from  its  disposition,  and  colloid  or 
glue-like  from  its  aspect.  The  general  characters  of  this  species 
of  degeneration  are  a tumour  affecting  a considerable  portion  of 
the  stomach,  most  commonly  the  anterior  and  posterior  portions  of 
the  large  ai’ch  of  the  organ  ; and  in  some  instances  the  cardiac 
portion  both  anteriorly  and  posteriorly.  It  does  not  seem  often  to 
commence  in  the  pyloric  portion  ; but  it  may  extend  from  the  car- 
diac or  the  middle  region  of  the  organ  to  ihapylorus.  The  tumour 
is  firm,  of  cartilaginous  consistence,  and  when  inspected  at  the 
mucous  surface  of  the  stomach  presents  the  aspect  of  a solution  of 
isinglass  which  has  become  coagulated,  with  a sort  of  honey-comb, 
or  reticular  surface  like  network.  The  colour  is  generally  light- 
gray  or  pearl-like.  The  structure  cuts  firm. 

The  morbid  structure  affects  primarily,  and  principally,  it  appears 
to  me,  the  mucous  membrane  of  the  stomach;  and  this  areolar  or 
colloid  form  of  cancer  is  more  frequently  observed  in  this  organ 
than  in  any  other,  or  in  any  other  texture.  It  consists  apparently 
in  the  infiltration  of  this  colloid  or  gelatiniform  matter  into  the  in- 
terstitial spaces  of  the  mucous  membrane.  It  renders  the  stomach 
thick  and  hard.  The  thickness  varies  from  one-fourth  of  an  inch 
to  half  air  inch,  and  to  three  quarters.  When  divided,  the  morbid 
structure  appears  like  a hard  or  tough  solution  of  firm  jelly  or 
isinglass,  with  numerous  communicating  cells. 

In  general  this  deposit  is  confined  to  the  mucous  membrane ; and 
the  muscular  coat  is  pale,  hard,  thicker  than  natural,  with  developed 
fibres,  and  in  a state  of  hypertrophy.  Several  authorities,  and  espe- 
cially Cruveilhier,  state  that  the  muscular  coat  is  also  affected  by 
this  deposit.  But  the  statement  appears  not  to  be  confirmed. 

It  is  also  said  that  this  deposit  affects  primarily  the  cellular  tissue 
of  the  stomach.  Such  appears  to  be  the  opinion  of  Breschet,  An- 
dral,  and  Raikem.  This  appears  to  be  still  more  doubtful  than  the 
previous  statement.  The  deposit,  originating  in  the  mucous  coat 

3 


MUCOUS  MEMBRANE. 


677 


of  the  stomach,  may  extend  to  the  cellular.  But  that  it  commences 
in  the  cellular  appears  at  present  to  be  a questionable  statement, 
which  requires  the  confirmation  of  further  inquiries. 

Scarpa,  though  not  aware  of  the  exact  character  of  areolar  or 
colloid  cancer,  shows,  nevertheless,  that  he  had  seen  every  reason, 
from  preparations  and  specimens  of  the  disease,  to  infer,  that  it 
commences  in  and  affects  the  mucous  membrane.* 

In  short,  areolar,  alveolar,  or  colloid  cancer,  is  to  be  distinguish- 
ed from  the  other  forms  of  this  morbid  deposit,  both  by  its  physical 
and  anatomical  characters,  by  its  arrangement,  and  by  the  tissues 
which  it  affects.  In  physical  aspect  it  is  semihard,  elastic,  like  stiff 
isinglass  solution.  In  internal  structure  it  is  cellular.  And  lastly, 
it  is,  if  not  exclusively  confined  to  the  stomach,  much  more  common 
in  that  than  in  any  other  organ. 

d.  A fourth  form  in  which  cancerous  disease  attacks  the  mucous 
tissues  is  that  of  lardaceous  degeneration.  In  certain  regions,  in- 
deed, this  is  so  rare  that  it  is  never  seen.  For  example,  though 
not  very  frequent  in  the  gastro-enteric  mucous  membrane,  it  has 
been  observed  in  the  oesophagus  and  rectum.  It  is  not  known  in 
the  tracheo-bronchial  membrane.  In  the  uterus,  however,  it  is  very 
common ; and  I have  seen  several  instances  in  which  the  neck  and 
part  of  the  body  of  this  organ  was  converted  into  a ceromatous  and 
apparently  inorganic  mass.  The  decomposition  of  this  morbid  de- 
position is  peculiar.  It  terminates  not  in  ulceration,  but  in  a species 
of  softening  and  pulpy  disorganization  or  liquefaction,  rendering 
the  decomposing  surface  doughy  or  pasty  like  soft  lard,  traversed 
by  marks  of  erosion  similar  to  those  produced  by  the  gnawing  of 
animals, 

§ 4.  Warty  excrescences  are  occasionally  found  in  mucous  mem- 
branes, They  consist  of  hard  eminences  often  fissured,  sometimes 
sessile  with  broad  base,  occasionally  peduncular,  and  occasionally 
pass  into  bad  ulceration.  They  are  most  frequent  in  the  pharyn- 
geal and  oesophageal,  and  in  the  cystic  and  uterine  membrane. 

§ 5.  Fungous  growths  or  excrescences  are  mentioned  as  occa- 
sionally found  in  the  mucous  tissues  ; but  little  accurate  informa- 
tion is  given  regarding  them.  They  are  frequent  in  the  bladder 

■*  “ Scirrhus  and  cancer  of  the  stomach,”  he  says,  “ always  begins  with  induration  of 
the  internal  mucous  membrane  of  the  organ,  which  becomes  thick,  hard,  cartila- 
ginous, then  ulcerates  ; and  from  the  inner  coat  the  disease  is  propagated  to  the  other 
membranes  of  the  stomach,  which  are  converted  into  scirrhus,  and  cancerous  hardness, 
with  ulceration.”  Memoria  Sullo  Scirro  et  sul  Cancro.  Opuscoli  di  Chirurgia  di  An- 
tonio Scarpa.  Vol.  i.  Pa\'ia  1825.  Folio  minore. 


678 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


of  the  male  (Lecat,  Sandilort,  Baillie,  Walter,  &c.)  and  the  uterus 
of  the  female,  but  appear  to  be  more  rare  in  other  regions.  It  is 
probable  that  these  excrescences  named  fungous,  are  in  truth  the 
products  of  an  advanced  stage  of  some  organic  change  either  al- 
ready noticed  or  to  be  noticed.  In  the  uterus,  for  instance,  authors 
mention  the  occurrence  of  reddish  tumours  not' unlike  masses  of 
clotted  blood,  which  are  manifestly  either  molce.,  or  fungus  hcsma- 
todes,  or  some  of  the  products  of  cancerous  ulceration.  In  other  in- 
stances, as  in  the  bladder,  these  fungous  growths  actually  issue  from 
the  mucous  membrane  in  a morbid  state,  sometimes  the  effect  of 
chronic  inflammation,  or  are  the  result  of  enlarged  prostate.  Upon 
the  whole,  accurate  facts  are  wanting  on  this  head. 

§ 6.  Though  hgdatids  are  enumerated  by  some  authors  among 
the  morbid  products  of  mucous  surfaces,  it  is  not  easy  to  understand, 
without  violation  of  certain  pathological  principles  supposed  to  be 
well-established,  the  reason  of  their  development  in  these  situations. 
Thus,  hydatids  have  been  stated  to  be  coughed  up  from  the  lungs, 
to  he  voided  from  the  intestines,  and  to  have  escaped  from  the  ute- 
rus. In  the  case  of  the  lungs,  they  are  formed  originally  in  the 
pleura  or  pulmonic  tissue,  from  which  they  find  their  way  to  the 
bronchial  membrane ; or  they  may  escape  from  the  liver  through  | 
the  diaphragm  ; (Dr  Foart  Simmons,  Dr  Monro.)  In  the  case  of  ij 
the  intestines,  they  are  also  in  all  probability  formed  in  the  liver  or  [ 
the  peritoneum,  and  thence  proceed  by  ulceration  into  the  intestinal 
cavity.  The  uterus,  in  short,  is  the  only  cavity  with  mucous  sur- 
face, in  which  inspection  shows  that  they  have  been  found.*  Ty- 
son, nevertheless,  states  that  he  found  them  in  the  bladder.f 
§ 7.  Deposition  of  bony  matter  in  certain  of  the  mucous  surfaces 
is  mentioned  by  various  authorities.  Thus  Metzger  records  an  in- 
stance of  ossification  of  the  oesophagus  Walter  one  of  bony 
deposition  in  the  inner  surface  of  the  pharynx  :§  De  Haen 
mentions  an  osseous  degeneration  of  the  stomach  ;1|  ShortIF  and 
others  mention  similar  deposits  in  the  colon  and  rectum  ; and 
Hody,**  Lettsom,ft  Baillie,  Odier,and  MackieJ^  mention  examples 

* Gregorini  Dissert.  Morgagni,  Epist.  xlviii.  13,  14.  Porta),  Anatomie  Aledicale, 
Tome  V.  p.  527, 528.  Rudolphi  gives  the  best  account  of  Hydatids  affecting  the  ute- 
rus and  other  organs.  Ueber  die  Hydatiden  thierischer  Korper,  in  Anatomisch-Physio- 
logische  Abhandlungen.  Berlin,  1802.  P.  190. 

t Phil.  Trans.  No.  188.  ^ Ed.  Med.  Essays,  Vol.  iv.  353.  | 

J Adversaria  Medica,  p.  176  and  177.  **  Phil.  Trans.  No.  440.  j 

§ Catalog!  AIus.  No.  1536.  -fT  Alem.  Med.  Society,  Vol.  v. 

|]  Rat.  Med.  Tom.  iv,  cap.  i.  ."I-'J  Med.  and  Phys.  Journal. 


MUCOUS  MEMBRANE. 


G79 


of  the  same  occurrence  in  the  uterus.  The  history  of  the  mode  of 
development  of  this  deposition  is  not  exactly  known ; and  it  is  not 
quite  certain  whether  the  ossification  originates  invariably  in  the 
mucous  corion.  This  indeed  appears  to  have  taken  place  in  the 
instance  mentioned  by  Walter,  and  in  such  cases  of  uterine  ossifi- 
cation as  that  recorded  by  Dr  Caldwell.  * In  instances  of  osseous 
deposition  in  the  alimentary  canal,  it  is  justly  suspected  by  Dr 
Monro  to  originate  in  the  muscular  fibres. 

§ 8.  Further,  in  certain  regions  of  the  mucous  tissue  are  found 
morbid  growths  which  are  proper  to  these  regions,  and  to  be  found 
in  no  other  part  of  the  mucous  membranes.  Thus  the  milt- like 
tumour  described  by  Dr  Monro  has  been  found  chiefly  in  the  sto- 
mach and  bowels ; and  the  fleshy  tubercle  of  William  Hunter  and 
Dr  Clark,  and  the  cauliflower  excrescence  of  the  latter,  are  found 
only  in  the  womb. 

The  former  variety  of  tumour,  for  an  accurate  description  of 
which  we  are  indebted  to  Dr  Monro  tertius,  resembles  in  structure 
and  consistence  the  milt  of  fishes,  is  of  a pale  red.  colour,  with  an 
irregular  surface,  and  is  covered  by  a thin  but  vascular  mem- 
brane, adheres  slightly  to  the  organ  from  which  it  grows  by  a num- 
ber of  small  vascular  processes  penetrating  the  mucous  corion,  which 
is  unnaturally  thick,  and  presents  a honey-comb  appearance.  The 
portion  of  intestine  to  which  such  tumour  is  attached  presents  marks 
of  vascular  injection.  The  substance  of  the  tumour,  though  misci- 
ble with  water,  which  it  renders  turbid,  is  indurated  by  immersion 
in  alcohol, — a circumstance  from  which  it  may  be  inferred  to  con- 
tain a proportion  of  albuminous  matter.  It  emits  a fetid  oflFensive 
smell,  and  communicates  tbe  same  to  the  organ  from  which  it  grows. 
It  is  chiefly  a disease  of  advanced  life, — a circumstance  by  which, 
with  others,  it  may  be  distinguished  from  hsematoid  fungus. 

The  fleshy  or  sarcoid  tubercle  of  the  uterus,  though  apparently 
not  unknown  to  Morgagni,  was  first  observed  by  William  Hunter, 
and  has  since  been  distinctly  described  by  Dr  John  Clarke,  Dr 
Baillie,!  and  Sir  C.  M.  Clarke.  | According  to  the  accounts  of 
these  observers,  it  appears  in  the  form  of  one  or  more  tumours  of 
hard  whitish  substance,  sometimes  as  firm  as  cartilage,  projecting 
from  the  mucous  surface  of  the  organ,  but  occasionally  growing 

* Med.  and  Surg.  Journ.  Vol.  ii.  22. 

t Morbid  Anatomy,  chap.  xix.  p.  37 i. 

t Observations  on  the  Diseases  of  Females,  part  i.  chap,  xviii.  p.  243, 


680 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


between  the  peritonaeal  coat  and  muscular  layer.  In'size  they  vary 
from  that  of  a pea  to  masses  of  several  pounds  ; and  in  shape,  though 
generally  spheroidal,  they  are  sometimes  irregular.  They  cause  a 
copious  mucous  discharge  and  much  local  irritation,  but  without 
much  affecting  the  constitution. 

The  cauliflower  excrescence  was  also  first  accurately  described 
by  Dr  John  Clarke ; * and  his  description  has  been  since  verified 
by  his  brother  Sir  C.  Mansfield  Clarke.  From  the  observations  of 
these  authors,  it  results  that  the  cauliflower  excrescence  arises  al- 
ways from  some  part  of  the  os  uteri.  When  first  recognised,  it 
forms  an  irregular  prominence,  with  a broad  base  and  a granulated 
surface.  As  the  tumour  increases  in  size,  the  granulated  structure 
of  its  surface  becomes  more  distinct,  and  begins  to  be  parted  into 
numerous  elongated  granules,  which  give  it  the  appearance  of  a 
cauliflower  when  it  begins  to  run  to  seed.  In  most  instances  these 
granules  are  friable  and  brittle,  and  break  off,  if  rudely  handled, 
in  the  form  of  minute  white  fragments ; and  indeed  such  fragments 
are  occasionally  or  periodically  discharged  with  the  urine  and  other 
fluids.  Its  surface,  which  is  of  a bright  flesh  colour,  is  covered  by 
a thin  delicate  membrane,  from  which  oozes  abundantly  a sero-al- 
buminous  fluid,  which  mats  the  linen  like  starch,  and  occasionally 
blood  flows  copiously.  In  married  women  who  have  had  children 
its  growth  is  rapid ; in  those  not  exposed  to  sexual  intercourse  it 
is  slow.  The  attempts  made  to  inject  this  growth  have  been  un- 
successful. The  injection  escapes  from  its  surface  rapidly;  and  it 
shrinks  so  much  after  death,  that  it  is  impossible  to  recognize  any- 
thing but  a small  loose  flocculent  membranous  prolongation  of  the 
part  to  which  it  is  attached.  These  circumstances,  with  its  hemor- 
rhagic character,  lead  Sir  C.  Clarke  to  regard  it  as  an  assemblage 
of  minute  arteries  similar  to  the  placental  structure.  It  is  probably 
a morbid  variety  of  erectile  tissue.f 

VII.  Displacements. — The  mucous  merahranes,  partly  in  con- 
sequence of  their  loose  connection  in  many  instances  with  subjacent 
tissues,  partly  in  consequence  of  inordinate  action  in  the  muscular 
fibres  of  their  proper  organs,  sometimes  in  consequence  of  inflam- 
mation, are  liable  to  various  unnatural  changes  of  situation.  Thus 
the  eyelids  are  liable  to  eversion,  the  rectum.!  vagina,  and  the 

* Transactions  of  a Society,  Vol.  iii.  p.  298. 

t Observations  on  those  Diseases  of  Females,  &c.  Part  ii. 


MUCOUS  MEMBRANE. 


681 


uterus  to  prolapsus  and  procidentia,  the  uterus  to  inversion,  and  the 
intestinal  canal  to  invagination  and  hernial  protrusion. 

VIIT.  Malforjmations. — § 1.  Lastly,  Malformations  are  fre- 
quently observed  in  the  mucous  system ; hut  it  is  often  difficult  to  dis- 
tinguish between  those  which  are  proper,  and  those  which  are  com- 
mon to  it  with  collateral  and  subjacent  tissues.  Occasionally,  for  in- 
stance, parts  of  the  mucous  system  in  common  with  the  other  con- 
stituent tissues  of  an  organ  are  wanting.  Thus  part  of  the  alimen- 
tary canal  may  be  deficient,  and  the  urinary  bladder  or  the  rectum 
has  been  known  to  be  wanting.  In  other  instances,  part  of  the 
mucous  tissue  of  one  organ  may  be  so  incomplete,  that  a direct 
communication  with  another  is  established.  Thus  the.  velum  may 
be  fissured  and  the  palate  may  communicate  directly  with  the  na- 
sal passages ; the  vagina  may  open  into  the  rectum,  the  bladder  in 
the  hypogastric  region,  or  communicate  directly  with  the  rectum ; 
or  the  urethra  may  open  into  the  perinseum.  The  mechanism  of 
malformations  of  this  description  is  to  be  explained  by  the  history 
of  the  development  of  the  mucous  system  during  the  early  months 
of  foetal  existence.  The  researches  of  Wollf,  Oken,  J.  F.  Meckel, 
and  Tiedemann,  show  that  a slight  interruption  given  to  the  pro- 
cess of  development  at  this  period,  while  the  cutaneous  and  mucous 
surfaces  are  in  direct  continuation  upon  the  mesial  plane,  is  suffi- 
cient to  continue  through  life  a peculiarity  of  structure,  which  be- 
longs only  to  the  embryo  during  formation. 

§ 2.  Congenital  Fistulaeoftheneck, — One  of  the  most  curious  exam- 
ples of  this  sort  of  malformation  is  furnished  by  the fistulce  of  the  neck 
described  by  Dzondi,*  Ascherson,f  and  Meyer.;];  These  fistulae  are 
in  general  known  by  a very  minute,  almost  imperceptible  aperture, 
on  the  lateral  surface  of  the  neck,  appearing  in  the  angle  formed 
by  the  internal  head  of  the  sterno-raastoid  muscle  and  the  sternal 
end  of  the  collar-bone,  or  at  the  inner  margin  of  that  muscle.  This 
is  the  external  aperture.  An  internal  one  is  not  in  all  cases  ob- 

* Carolus  Henricus  Dzondi,  Phil.-Doct.  et  Chir.-Doct.  De  Fistulis  Trachea  Con- 
genitis,  Commentatio  Pathologico-Therapeutica.  Halae,  1829.  8vo. 

-f-  Ferdinandus  Mauritius  Ascherson,  M.  D.,  De  Fistulis  Colli  Congenitis.  Adjecta 
Fissurarrim  Branchialium  in  Mammalibus,  Avibusque,  Historia  Succincta.  BeroKni, 
183-2.  4to. 

t De  Fissuris  Hominis  Mammaliumque  Congenitis.  Accedit  Fissurse  Buccalis  Con- 
genitae  cum  Fissur<e  Tubs  Eustachii  et  Tj-mpani  Complicats  Descriptio.  Auctore 
Conrado  Meyer  Tigurino  ; Medicins  utriusque  Doctore.  Cum  quatuor  tabulis  sneis. 
Berolini,  1835.  Folio. 


682 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


served.  The  course  of  the  fistula^  which  is  so  small  as  often  to  ad- 
mit only  the  lacrymal  probe  of  Anel,  is  in  general  towards  the 
pharynx  ; and  in  some  cases  water  may  be  injected  by  the  fistula 
into  the  pharynx. 

r rom  the  external  aperture  of  these  fistulce  exudes,  from  time  to 
time,  a thin  white  drop  of  transparent  glutinous  fluid,  not  unlike 
white  of  egg,  sometimes  like  purulent  matter.  The  inner  surface 
of  these  fistulse  is  smooth,  reddish,  and  like  that  of  a mucous  mem- 
brane. 

These  fistulae,  which  are  congenital,  are  the  remains  of  the  bran- 
chial slits  of  the  early  intra-uterine  period  of  the  foetus,  in  conse- 
quence of  the  process  of  closure  of  these  slits  being  in  some  manner 
stopped.  They  cannot  be  healed  without  inconvenience  ; in  one  case 
the  attempt  was  followed  by  apoplectic  death ; and  there  is  reason 
to  believe  that  they  must  have  been  left  open  for  some  salutary  pur- 
pose. 

They  are  more  frequent  in  females  than  in  males  in  the  ratio  of 
about  eight  to  three. 

They  are  observed  in  certain  families  more  commonly  than  in 
others. 

§ 3.  The  sacs  of  the  ileum  and  bladder,  called  diverticula,  appear  to 
depend  on  deficiency  of  the  muscular  layer,  in  consequence  of  which 
the  mucous  corion  is  protruded  through  the  defective  space.  (Mor- 
gagni ; Palletta.) 

§ 4.  In  other  instances,  deviations  from  the  normal  arrangement 
consist  in  unnatural  unions  of  mucous  surfaces,  rendering  the  canals 
which  they  line  impervious,  and  constituting  varieties  of  imperfora- 
tions.  Thus  the  pyloric  orifice  of  the  stomach  has  been  found 
closed,*  the  rectum  imperforate,  and  the  vagina  imperforate.  These, 
in  all  probability,  are  to  be  ascribed  to  deficiency  of  mucous  mem- 
brane, in  consequence  of  which  the  contiguous  parts  contract  ad- 
hesion. 

§ 5.  In  other  instances,  again,  malformations  are  the  result  of  dis- 
ease. Of  this  description  are  the  enlarged  or  distended  state  of  the 
pulmonic  vesicles,  produced  by  several  being  hurst  into  one  large 
cavity ; the  central  contraction  of  the  stomach ; the  sacculated  state 
of  the  urinary  bladder;  the  dilatations  of  the  alimentary  canal,  in 
consequence  of  the  lodgement  of  foreign  bodies  or  concretions ; 

* Case  bv  Mr  Crooks,  Edin.  Med.-Chirur.  Transactions,  Vol.  ii.  589. 

4 


SEROUS  MEMBRANE. 


. 683 


and  those  of  the  gall-bladder  or  gall  ducts,  in  consequence  of  the 
presence  of  gall-stones.  Another  variety  of  the  same  description 
of  malformation  consists  in  the  fistulous  openings  occasionally 
eflTected  between  the  mucous  membranes  and  the  cutaneous  sur- 
face by  the  process  of  progressive  ulceration.  To  this  head  be- 
long the  Jistulae  of  the  stomach,  of  which  many  examples,  from 
wounds  and  similar  injuries,  as  well  as  spontaneous  abscesses, 
are  now  recorded ; the  Jistulae  which  result  from  the  ulceration 
caused  by  the  discharge  of  gall-stones ; artificial  anus  so  frequent 
after  intestinal  inflammation,  and  especially  that  which  attends 
strangulated  hernia ; urinary  fistulse,  whether  taking  place  from 
the  bladder  in  the  hypogastrium  or  rectum,  or  from  the  urethra ; 
and  destruction  of  the  recto-vaginal  septum  in  females,  either  by 
laceration  or  ulceration.  These  fistulse  are  covered  by  a smooth 
callous  membrane  so  similar  in  its  properties  to  mucous  texture 
that  John  Hunter,  Meckel,  and  some  other  authors  think  it  not  an 
extravagant  or  gratuitous  hypothesis  to  regard  them  as  examples  of 
the  abnormal  development  of  mucous  texture. 


CHAPTER  HI. 

Section  I. 

SEROUS  MEMBRANE,  TRANSPARENT  MEMBRANE  ; Membrann 

pellucida, — M.  serosa  ; — Tiss?i  Sereux. 

The  pleura  and  peritonaeum  are  the  best  examples  of  the  tissue, 
which  has  been  named  serous,  from  the  fluid  with  which  it  is  moist- 
ened, and  which  may  be  termed  transparent  or  diaphanous  as  its 
distinctive  character. 

The  distribution  or  mechanical  arrangement  of  these  membranes 
is  peculiar,  and  was  not  well  understood  by  anatomists  till  Douglas, 
in  1730,**^  by  his  description  of  the  peritonaeum,  rendered  it  clearer 

A Description  of  the  Peritoneum,  and  of  that  part  of  the  Membrana  Cellularis 
which  lies  on  its  outside.  With  an  Account  of  the  true  situation  of  all  the  Abdo- 
minal Viscera  in  respect  of  these  two  Membranes.  By  Dr  James  Douglas,  Physician 
in  ordinary  to  her  Majesty,  &c.  London,  1730.  4to. 


684 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


and  more  intelligible.  Since  that  time  the  distribution  of  these 
membranes,  individually  and  generally,  has  been  elucidated  by  the 
labours  of  Hunter,  Carmichael  Smyth,  and  Bichat,  with  a degree 
of  perspicuity  and  precision  which  leaves  little  to  be  done  by  sub- 
sequent observers.  Notwithstanding  this,  Valentin  Hansen  of 
Triers,  a learned  student  of  the  University  of  Berlin,  thought  it, 
in  1834,  a subject  worthy  of  further  inquiry  and  explanation  ; and 
his  dissertation  must  be  allowed  to  be  a good  memorial  of  industry 
and  intelligence.* 

In  this,  nevertheless,  there  are  certain  peculiarities  which  may 
perplex  the  beginner,  and  prevent  him  from  obtaining  at  first  a 
clear  idea  of  the  distribution  and  configuration  of  the  pellucid 
membranes.  Thus  they  have  neither  beginning  nor  termination  ; 
they  have  neither  orifice  nor  egreclient  canal ; and  they  are  not 
continuous  with  any  other  membrane  or  texture. 

§ 1.  Every  serous  membrane  consists  of  a hollow'  sac  everywhere 
closed,  and  to  the  cavity  or  interior  surface  of  which  there  is  no 
natural  entrance,  a circumstance  from  which  they  have  been  deno- 
minated shut  sacs,  {sacci  occlusi ; sacs  sans  ouverture.')  In  every 
serous  membrane  one  part  is  inverted  or  inflected,  or  reflected,  as 
is  commonly  said,  within  the  other,  so  that  the  inner  surface  of  the 
former  part  is  applied  with  more  or  less  accuracy  to  the  inner  or 
like  surface  of  the  latter.  This  mode  of  disposition  has  suggested 
to  anatomists  the  homely  and  trite,  but  not  inappropriate  compa- 
rison of  a serous  membrane  to  a nightcap,  one-half  of  which  is 
folded  or  doubled  within  the  other,  so  that  while  one-half  of  the 
inner  surface  is  applied  to  the  remaining  half,  no  communication 
exists  between  the  inner  and  the  outer  surface.  Every  serous 
membrane,  in  short,  is  a single  sac,  one-half  of  which  is  doubled 
within  the  other. 

In  every  serous  membrane  the  outer  surface  of  the  unreflected 
portion  is  applied  over  the  walls  of  the  region  which  the  serous 
membrane  lines,  while  the  outer  surface  of  the  inflected  portion  is 
applied  over  the  organ  or  organs  contained  in  that  region.  From 
this  arrangement  it  results  that  each  organ  covered  by  serous  mem- 
brane is  not  contained  in  that  membrane,  but  is  on  its  exterior  sur- 

’ Peritonaei  Humani  Anatomia  et  Physiologia,  Dissertatio  Inaug.  Quam  pro  sum- 
mis  in  Medicina  et  Chirui’gia  Honoribus  in  Universitate  Literaria  Frederica  Guilelma, 
rite  sibi  conciliandis,  die  21  Junii  1834,  publice  defendet  Auctor  Valentinus  Hansen 
Rhenano-Borussus.  4to. 


SEROUS  MEMBRANE. 


685 


face,  and  that  of  every  organ  so  situate,  one  part  at  least,  viz.  that 
at  which  its  vessels  and  nerves  enter,  is  always  uncovered.  Thus 
the  lungs  are  on  the  outer  surface  of  the  pleura  ; the  heart  is  on 
the  outside  of  pericardium  ; the  stomach,  intestines,  liver,  spleen, 
and  pancreas  are  on  the  outside  of  the  peritonceum  ; and  the  tes- 
ticles are  on  the  outside  of  the  peridydimis.  In  the  same  manner 
the  lungs,  though  invested  by  pleura  before  and  behind,  at  their 
apex  and  their  base,  are  uncovered  at  their  roots,  or  the  points 
where  the  bronchial  tubes  and  great  blood-vessels  enter  their  sub- 
stance ; the  heart  is  uncovered  by  pericardium  at  the  upper  part 
of  the  auricular  cavities ; and  the  intestinal  canal  is  uncovered 
along  the  whole  of  that  longitudinal  but  tortuous  line  by  which  the 
mesentery  is  attached,  and  at  which  its  proper  vessels  and  nerves 
are  transmitted. 

To  comprehend  the  arrangement  of  the  pellucid  membranes  still 
more  distinctly,  it  is  expedient,  by  an  effort  of  abstraction,  to  trace 
the  course  of  any  one  of  them,  having  previously  thrown  out  of  the 
question  the  necessary  means  by  which  their  interior  or  free  sur- 
face is  exposed.  In  this  mental  process,  also,  it  is  requisite  to  re- 
member that  there  is  no  initial  point  save  what  is  arbitrarily  made. 
If,  for  example,  the  course  of  the  pleura  be  traced,  the  membrane 
presents  no  natural  mark  or  boundary  from  which  the  anatomist  is 
to  commence  his  demonstration ; and  he  must  fix  artificially  on 
any  point  which  he  finds  most  convenient  for  the  purpose.  Com- 
mencing with  this  understanding,  from  the  circumference  of  the 
spot  termed  root  of  the  lungs,  the  membrane  may  be  traced  first 
along  the  internal  surface  of  the  chest  formed  by  the  ribs  and  in- 
tercostal muscles,  forwards  to  tbe  sternum,  upwards  to  the  first  rib 
and  apex  of  the  thoracic  cavity,  and  downwards  to  the  diaphrag- 
matic insertions,  and  over  the  surface  of  that  muscle,  and  the  outer 
surface  of  the  pericardium  again,  to  the  circumference  of  the  root 
or  connection  of  the  lungs.  From  this  point  again  it  may  be  traced 
over  the  surface  and  between  the  lobes  of  these  organs,  both  of 
which,  as  already  stated,  are  thus  situate  on  the  outside  of  the 
pleura.  The  course  first  described  is  that  of  the  unrejlected  or  ex- 
terior division  of  the  pleura.  The  second,  or  that  over  the  organ 
covered,  is  the  course  of  the  inflected  or  doubled  portion  of  the  mem- 
brane, which  is  thus  necessarily  smaller  and  less  extensive  than  the 
former. 

The  arrangement  thus  sketched,  which  may  be  easily  shown  to 


686 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


be  applicable  to  all  the  serous  membranes,  demonstrates  their  two- 
fold character  of  lining  the  walls  of  a cavity  and  covering  the  organs 
contained.  From  an  idea  of  this  property  the  older  anatomists 
applied  to  them  the  epithet  of  membranes  succingentes. 

In  tracing  the  course  of  the  serous  membranes,  the  anatomist 
observes,  that  they  present  productions  which  float  with  more  or  less 
freedom  in  the  cavity  formed  by  the  free  surface,  and  which  may  be 
generally  shown  to  consist  of  two  folds  of  the  single  membrane  pro- 
duced beyond  the  inclosed  organ,  but  still  maintaining  the  unity  of 
the  membrane.  Of  these  prolongations,  the  most  distinct  examples 
are  the  epiploon  and  the  appendices  epiploicce  of  the  peritonaeum. 
Less  manifest  instances  are  the  adipose  folds  of  the  pleura  near  the 
mediastinum,  and  the  bladder-like  appearance  at  the  base  of  the 
heart,  within  the  pericardium.  The  synovial  fringes  in  the  interior 
of  the  synovial  membranes,  which  belong  to  a subsequent  head,  are 
nevertheless  of  the  same  general  character.  Between  the  folds  of 
these  productions  there  is  invariably  more  or  less  adipose  substance, 
which  indeed  is  observed,  in  some  quantity,  in  various  parts  of  the 
filamentous  tissue  on  the  outer  surface  of  the  serous  membranes  in 
general. 

Every  serous  membrane  I have  above  represented  as  a hollow 
sac  everywhere  continuous,  and  the  outer  surface  of  which  has  no 
communication  with  the  inner.  To  this  character  the  only  excep- 
tion is  the  peritonasum  in  the  female,  which  is  perforated  at  two 
points,  corresponding  to  the  upper  extremity  or  orifice  of  the  Fal- 
lopian or  oviferous  tubes.  This  has  been  already  mentioned  as  the 
only  spot  at  whieh  the  mucous  and  serous  surfaces  communicate 
directly  with  each  other. 

Every  serous  membrane  may  be  described  as  consisting  of  a very 
thin,  colourless,  transparent  web  or  pellicle,  through  which  the 
tissue  of  the  subjacent  organ  or  parts  may  be  easily  recognized ; and 
every  serous  membrane  presents  two  surfaces,  an  attached  or  ad- 
herent, and  a free  or  unadherent. 

The  attached  surface,  which  is  also  termed  its  outer  one,  is  that 
by  which  it  is  connected  to  the  tissue  or  organ  which  it  covers ; it 
is  somewhat  irregular,  flocculent  or  tomentose,  and  is  evidently  con- 
nected by  fine  filamentous  tissue.  The  degree  of  attachment  is  very 
variable  in  different  membranes,  and  in  different  points  of  the  same 
membrane.  In  general  serous  membranes  adhere  much  less  firmly 
to  the  walls  of  cavities  than  to  the  surface  of  the  contained  organs. 


SEROUS  MEMBRANE. 


687 


Thus  the  abdominal  peritonaeum  and  the  costal  pleura  are  more 
easily  removed  than  the  intestinal  peritonaeum  and  the  pulmonic 
pleura.  The  peritonaeum  adheres  feebly  to  the  bladder,  to  the 
liver,  and  to  the  pancreas,  more  intimately  to  the  differenUregions 
of  the  intestinal  tube,  and  seems  to  be  almost  identified  with  the 
substances  of  the  female  organs  of  generation.  From  the  in- 
terior of  the  capsular  pericardium  and  from  the  vaginal  coat 
it  is  almost  impossible  to  detach  the  serous  pellicle.  The  former, 
however,  I shall  have  occasion  to  show,  is  peculiar  in  having  between 
the  serous  surface  and  the  fibrous  membrane  no  filamentous  tissue, 
upon  the  abundance  or  deficiency  of  which  the  degree  of  adhesion 
depends. 

The  free  or  unadherent  surface,  which  has  been  also  named  inner ^ 
is  very  smooth  or  polished  and  uniform,  moistened  with  a watery 
fluid,  fi’om  which  it  derives  in  some  degree  its  shining  appearance, 
and  completely  destitute  of  fibres  or  any  other  trace  of  organic 
structure.  From  this  smooth  polished  aspect,  which  is  a peculiar 
attribute  of  the  free  surface  of  serous  membrane,  all  the  organs 
covered  by  it  derive  their  glistening  appearance.  Thus  the  exte- 
rior surface  of  the  lungs  derives  its  appearance  from  the  pleura,  the 
heart  from  the  pericardium,  the  liver  and  intestinal  canal  from  the 
peritonaeum.  A successful  injection  of  size  or  turpentine,  colour- 
ed with  vermilion,  brings  into  view  so  many  capillary  blood-vessels 
in  this  membrane,  that  it  might  be  supposed  at  first  sight  to  con- 
sist entirely  of  minute  arteries  and  veins.  F arther,  by  proper  ma- 
nagement, lymphatics  may  be  injected  in  it  with  quicksilver  to  a 
degree  equally  minute  and  delicate.  From  these  experiments, 
therefore,  it  may  be  concluded,  that  serous  membrane  is  chiefly 
composed  of  minute  arteries  and  veins  conveying  colourless  fluids, 
and  of  vessels  connected  with  the  general  trunks  of  the  lymphatic 
system.  Whether  it  contain  anything  else  but  vessels  of  this  kind, 
or  has  a proper  substance  or  tissue,  remains  to  be  ascertained. 
Though  nerves  are  often  seen  passing  along  their  outer  or  attach- 
ed surface  to  the  neighbouring  tissues,  none  have  hitherto  been 
traced  either  into  the  pleura  or  peritonaeum. 

By  most  of  the  older  anatomists,  and  among  others  by  Haller 
and  William  Hunter,  serous  membrane  is  considered  as  of  the  na- 
ture of  filamentous  tissue  or  cellular  membrane,  more  or  less  closely 
condensed,  {tela  cellulosa  stipata  ,•)*  and  this  view  is  adopted  and 
* Elem.  Physiolog.  Lib.  iv.,  sect.  i.  § i.  xvi.  Lib.  xxii. 


688 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


maintained  by  Bordeu,*  Bichat, f Meckel, | and  Beclard,§  the  last 
of  whom,  however,  thinks  they  partake  of  ligamentous  characters. 
Macerated  they  become  soft,  thick,  and  pulpy  ; and  are  finally  re- 
solved into  flocculent  filamentous  matter.  In  the  course  of  decom- 
position in  the  dead  subject  they  first  lose  their  glistening  aspect, 
then  become  covered  by  a foul  dirty  coating  of  viscid  matter,  which 
appears  to  exude  from  their  surface ; and  eventually  they  are  dis- 
solved into  shreds.  Immersion  in  boiling  water  renders  them  thick, 
firm,  and  somewhat  crisp.  When  dried  they  become  thin,  clear, 
and  transparent,  and,  if  preserved  from  humidity  or  the  attacks  of 
animals,  may  remain  long  unchanged.  The  experiments  of  Hat- 
chett, Fourcroy,  and  Vauquelin,  show  that  they  contain  gelatin  and 
a little  albumen  ; but  no  precise  information  on  their  chemical  com- 
position has  yet  been  given. 

The  principal  character  of  the  serous  membranes  is  that  of  iso- 
lating the  organs  which  they  cover,  and  to  the  structure  of  which 
they  are  foreign  or  adventitious,  and  forming  shut  cavities,  in  which 
there  is  an  incessant  process  of  exhalation  and  absorption.  In  some 
instances  they  evidently  contribute  to  facilitate  the  mutual  motions 
of  contiguous  and  corresponding  parts  and  surfaces.  From  their 
free  surfaces  is  secreted  a fluid  containing  a very  small  portion  of 
albumen,  (Hewson,||  Bostock,f)  which  is  greatly  augmented  during 
the  state  of  disease. 

The  mode  of  development  of  the  pellucid  membranes  is  not  very 
well  ascertained.  The  investigations  regarding  organogenesy  by 
Oken,  Meckel,  and  Tiedemann,  to  which  I have  occasion  so  fre- 
quently to  allude,  disclose  facts  which  induce  Meckel  to  hazard  the 
opinion  that  some  of  them  are  not  at  all  times  shut  sacs.  I have 
some  reason  to  doubt,  however,  whether  the  fact  which  he  adduces 
for  this  purpose  necessarily  implies  the  open  condition  of  the  peri- 
cardium and  the  peritonaeum.  In  the  case  of  the  former  the  de- 
velopment of  the  heart  proceeds  from  the  basis  generally,  without 
affecting  the  integrity  of  the  investing  membrane.  In  the  case  of 
the  latter  there  is  more  reason  to  believe,  that  at  the  navel  at  least 
the  peritonaeum  is  either  open,  or  is  continuous  with  the  vitellar 
membrane. 

* Recherches  sur  le  Tissu  Muqueux,  sect.  i.  § i. 

•j-  Anat.  Generale,  Tome  iv.  p.  S73.  + Handbuch,  B.  i. 

§ Elemens  d’Anat.  Gen.  p.  228. 

II  Experimental  Inquiries,  ii.  chap.  vii. 

H Nicholson’s  Journal,  Vol.  xiv.  p.  147,  and  Medico-Chirurg.  Tr.  Vol.  iv. 


SEROUS  MEMBRANE. 


689 


In  the  foetus  the  serous  membranes  are  so  thin,  that  they  are 
much  more  transparent  than  in  the  adult.  In  small  animals  also, 
they  are  more  transparent  than  in  lai’ge,  and  in  cold-blooded  ani- 
mals than  in  the  mammiferous.  Of  some  also  the  disposition  va- 
ries at  different  periods.  Thus  the  descent  of  the  testicle, — a pro- 
cess which  has  been  so  well  explained  by  Albinus,  Haller,  Wris- 
berg,  and  Langenbeck, — is  necessarily  attended  with  a remarkable 
change  in  the  arrangement  of  that  portion  of  peritonaeum  which 
the  gland  impels  before  it. 

The  above  description  applies  chiefly  to  the  general  characters 
and  properties  of  serous  membranes.  I have  yet,  however,  to  ad- 
vert to  certain  forms  of  this  tissue,  which,  though  similar  in  gene- 
ral characters,  present  too  many  peculiarities  to  be  justly  identified 
with  them.  The  first  which  I notice  as  least  different  is  the  -peri- 
cardium, or  capsule  of  the  heart ; the  second  is  the  arachnoid  mem- 
brane, which  shall  be  examined  with  the  cerebral  envelopes. 

§ 2.  The  capsule  of  the  heart  {pericardium)  consists  of  two  portions 
or  layers,  an  outer  or  proper  capsular,  and  an  inner  or  lining  di- 
vision. The  outer  or  proper  capsular  part  of  the  pericardium  pos- 
sesses the  characters  of  a fibrous  membrane,  of  some  density  and 
considerable  strength.  When  properly  washed  its  colour  is  gray 
or  grayish-white,  and  it  appears  to  consist  of  very  minute  fibrous 
threads,  which  are  arranged  without  any  definite  order.  These 
fibres  are  most  distinct  at  its  lower  margin,  where  it  is  connected 
to  the  circumference  of  the  tendinous  part  of  the  diaphragm.  In 
the  young  subject  it  is  generally  thin  and  translucent ; in  adult 
age  or  advanced  life  it  is  thicker  and  more  opaque.  This  part 
of  the  pericardium  is  a mere  investing  membrane,  which  bounds  the 
region  containing  the  heart,  but  which  extends  no  further.  It 
embraces  the  origins  of  the  large  vessels  above,  adheres  to  the 
margins  of  the  tendinous  centre  below,  and  is  on  each  side  con- 
nected with  the  pleura. 

When  the  pericardium  is  slit  open,  its  inner  surface  has  the  ap- 
pearance of  a transparent  or  serous  membrane,  through  which  the 
fibres  of  the  outer  or  capsular  part  may  be  seen,  and  which  has  the 
usual  glistening  aspect  of  such  membranes.  It  is  difficult,  however, 
to  insulate  it  from  the  outer  layer,  unless  by  boiling,  when  it  may 
be  peeled  off  in  minute  shreds. 

Like  the  transparent  membranes,  this  inner  layer  has  neither 
beginning  nor  end,  neither  origin  nor  termination.  After  lining 

X X 


690 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  inner  surface  of  the  proper  capsule,  it  may  he  traced  from  the 
angle  at  which  this  capsule  a:clheres  to  the  large  arteries  and  veins, 
over  the  auricles,  and  finally,  over  the  outer  surface  of  the  ventricles 
to  the  apex  of  the  heart. 

In  this  whole  course,  it  preserves  the  characters  of  a thin  trans- 
parent membrane,  with  a free  surface  and  an  attached  one.  The 
free  surface  is  perfectly  smooth,  glistening,  and  moistened  with  a 
watery  fluid.  The  attached  surface  adheres,  on  the  one  hand,  to 
the  inner  surface  of  the  capsule,  and  on  the  other,  to  the  outer 
surface  of  the  heart,  by  means  of  fine  filamentous  tissue. 

Injection  shows  that  the  pericardium  consists  chiefly  of  minute 
arteries  and  veins.  The  substance  of  the  capsular  part  is  probably 
a modification  of  the  white  fibrous  system;  but  it  requires  to  be 
more  carefully  examined.  No  nerves  have  been  traced  into  any 
part  of  this  membrane,  nor  is  it  quite  certain  that  it  contains  lym- 
phatics. 

§ 3.  The  cerebral  membranes  are  not  uniform  in  nature,  and  can- 
not be  conveniently  referred  to  any  head  save  that  of  compound 
membranes.  TYiedura  mater  is  fibrous;  the  fia  mo.ter  is  supposed  to 
be  celluloso-vascular ; and  Bichat  has  laboured  to  demonstrate  that 
the  arachnoid  is  a serous  membrane, — a view  which  is  adopted  by 
Meckel  and  Bedard,  but  rejected  by  Gordon.  By  configuration 
and  disposition,  I believe  it  is  more  easily  referable  to  this  than  to 
any  other  class  ; and  I therefore  introduce  its  anatomical  history 
in  this  place. 

The  brain  has  been  said  to  be  surrounded  by  three  membranous 
envelopes,  the  hard  membrane  {meninx  dura^  dura  mater)^  the  web- 
like membrane  {tunica  arachnoidea)^  and  the  soft  or  thin  membrane 
{meninx  tenuis,  pia  mater.')  There  is  perhaps  no  great  or  just  ob- 
jection to  this  arrangement,  which  has  been  adopted  by  almost  all 
writers.  But  it  simplifies  the  subject,  without  impairing  the  truth 
of  what  is  observed,  to  I’efer  them  to  two  only  ; one  of  which,  the 
hard  membrane  {meninx  dura,  dura  mater'),  is  com- 

mon to  the  brain  with  the  inner  surface  of  the  skull ; the  other, 
the  thin  membrane  {meninx  tenuis,  Mvr/^  Xevrrt,  pia  mater'),  is  pro- 
per to  the  brain  only.  They  may  be  distinguished,  therefore,  by 
the  terms  common  membrane  of  the  brain  and  proper  membrane  of 
the  brain.  The  arachnoid,  again,  is  a pellucid  web  common  to  the 
two  cerebral  membranes. 

The  first  of  these,  the  common  or  hai-d  cerebral  membrane  {me- 
3 


SEROUS  JIEMBRANE. 


691 


ninx  dura,  dura  mater),  presents  two  surfaces,  an  outer  or  cranial, 
and  an  inner  or  cerebral.  The  outer  surface  is  irregular,  filamen- 
tous, and  vascular ; and  the  substance  of  which  it  consists  is  dis- 
tinctly fibrous.  The  fibres,  however,  do  not  follow  any  uniform 
direction,  hut  are  interwoven  irregularly.  Maceration  causes  this 
membrane  to  swell  and  become  separated  into  fibrous  threads.  It 
is  well  known  that  it  is  liberally  supplied  with  blood-vessels,  and 
that  it  is  connected  by  these  to  the  inner  surface  of  the  skull.  No 
nerves  or  absorbents  have  been  discovered  in  it.  This  outer  or 
cranial  surface  of  the  dura  mater  is  manifestly  of  the  nature  of  pe- 
riosteum. Its  vessels  may  be  ti’aced  into  the  inner  table ; it  con- 
tributes to  the  formation  of  the  cranial  bones  in  the  foetus ; and 
various  facts  show  that  it  contributes  to  their  nutrition  during  life. 

The  inner  or  cerebral  surface  of  this  membrane  is  very  smooth, 
uniformly  polished,  and  shining  ; and  when  examined  in  water,  it 
appears  to  be  formed  of  a very  thin,  transparent  membrane,  through 
which  the  cranial  or  outer  surface  and  the  fibrous  structure  of  the 
hard  membrane  may  easily  be  recognized.  This  pellucid  inner 
membrane,  which  is  termed  by  Baillie  the  inner  lamina,  I shall  af- 
terwards show,  is  the  exterior  division  of  the  arachnoid  membrane. 

The  dura  mater  is  an  extensive  membrane,  and  lines  not  only 
the  interior  surface  of  the  skull,  but  that  of  the  whole  vertebral 
column.  Here  indeed  it  undergoes  some  modification.  The  inner 
surface  of  each  vertebra  has  a proper  periosteum  continuous  with 
the  periosteum  of  the  outer  surface  ; and  from  this  issues  a quan- 
tity of  filamentous  tissue,  which  penetrates  directly  a membranous 
canal,  evidently  of  fibrous^structure,  (theca  vertebralis,)  tough  and 
firm,  but  more  delicate  than  the  cranial  dura  mater.  The  dura 
mater  in  its  course  forms  sundry  prolongations  ; for  instance,  the 
large  crescentic  one  named  the  falx,  the  horizontal  otte  termed 
tentorium,  and  the  small  crescentic  one  named  falx  minor  or  cere- 
belli. 

The  thin,  soft,  or  immediate  and  proper  cerebral  membrane, 
(jjia  mater,  meninx  temds,)  presents  in  like  manner  two  surfaces,  a 
smooth  or  cranial,  which  is  exterior,  a filamentous  or  cerebral, 
which  is  interior  and  central. 

The  outer  or  smooth  surface  of  the  thin  membrane,  {pia  mater,) 
has  a glistening  appearance;  and  if  examined  attentively  it  is 
found  to  be  formed  by  a very  thin  transparent  membrane,  exactly 
similar  to  that  which  forms  the  cerebral  surface  of  the  dura  mater. 


G92 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


It  is  possible  to  recognize  through  it  the  subjacent  cerebral  part  of 
the  membrane,  its  vessels  and  the  appearance  of  the  brain  itself. 
This  surface  has  been  named  in  the  ordinary  'woi’ks  the  web-like 
membrane,  {tunica  arachnoidea).  It  is  believed  to  be  a separate 
membrane  from  the  pia  mater  ; but  that  which  forms  the  inner  or 
cerebral  surface  of  the  dura  mater  has  a claim  equally  strong  to 
this  distinction. 

The  inner  or  cerebral  surface  of  the  proper  or  soft  membrane, 

I have  already  said,  is  filamentous,  flocculent,  and  somewhat  rough. 

It  indeed  presents  a surface  which  sends  out  many  angular  pro- 
cesses of  animal  substance,  which  is  filamentous  and  loose  in  ap- 
pearance, and  which  evidently,  by  numerous  minute  vessels,  arte- 
ries, and  veins,  communicates  with  the  convoluted  surface  of  the 
brain.  These  processes,  which  are  the  Tomenta  of  the  ancient 
anatomists,  correspond  to  the  furrows  of  the  convoluted  surface  in 
which  they  are  lodged.  In  detaching  the  membrane  from  this 
part  of  the  brain,  numerous  vessels  are  observed  to  be  drawn  out 
of  its  substance ; and  when  the  membrane  is  injected  these  vessels 
may  be  seen  distinctly  filled,  and  communicating  with  the  gray 
matter  of  the  convoluted  surface.  The  veins  of  this  membrane 
may  be  traced  to  the  sinuses  in  those  large  longitudinal  vessels 
which  are  lodged  in  folds  of  the  hard  membrane. 

After  suitable  injection,  it  is  difficult  to  perceive  any  thing  but 
arteries  and  veins  in  the  proper  cerebral  membrane.  Neither 
nerves  nor  absorbents  have  yet  been  recognized  in  it.  Bichat  con- 
siders that  it  contains  a notable  quantity  of  cellular  tissue.  This, 
however,  is  denied  by  Gordon,  who  could  not  recognize  such  tis- 
sue. The  difference,  however,  consists  merely  in  name.  The  pia 
mater,  indeed,  possesses  no  cellular  tissue  like  the  subcutaneous, 
tbe  submucous,  or  the  subserous.  If,  however,  a portion  of  the 
arachnoid  be  peeled  from  it  by  careful  management  of  the  forceps 
and  blowpipe,  there  is  found  a quantity  of  loose  filamentous  or 
flocculent  matter,  which  evidently  unites  this  tissue  to  the  finer  web 
of  the  former.  It  is  further  remarkable  that  Dr  Gordon  himself 
admits  that  the  inner  surface  (he  should  have  said  the  outer  or 
attached)  of  the  arachnoid  membrane  is  more  or  less  thready  or 
flocculent,  according  to  its  connection  with  the  pia  mater,  without 
seeming  to  be  aware  that  this  thready  appearance  is  occasioned  by 
filamentous  tissue.  Lastly,  the  existence  of  this  tissue  between  the 

4 


SEROUS  MEMBRANE. 


693 


pia  mater  and  arachnoid  is  unequivocally  demonstrated  by  the  phe- 
nomena of  serous  infiltration. 

The  distribution  and  configuration  of  the  pia  mater  is  peculiar ; 
and  correct  knowledge  of  these  is  requisite  in  order  to  understand 
its  pathological  relations.  The  pia  mater,  or  proper  membrane  of 
the  brain,  consists  of  two  parts,  an  outer,  covering  the  convoluted 
surface  of  the  brain,  and  an  inner  or  central,  entering  the  cavities 
formed  by  the  inner,  central,  or  figurate  surface,  and  spread  over  this 
surface  in  the  form  of  what  has  been  termed  the  vascular  or  choroid 
web  ; {plexus  ctioroides  ; tela  clioroidea.')  The  arrangement  of  the 
first  or  exterior  division  of  the  cerebral  membrane  is  well  known. 
Its  flocculent-vascular,  or  tomentose  surface,  is  applied  closely  and 
immediately  to  every  part  of  the  convoluted  surface,  both  eminences 
and  depressions  {gyri  et  sulci) ; to  every  part  of  the  foliated  surface 
of  the  cerebellum  in  like  manner ; and  finally,  though  in  a more 
delicate  form,  to  the  surface  of  the  spinal  chord,  transmitting  those 
vessels  which  enter  and  issue  from  the  substance  of  each  part. 

The  continuity  of  the  pia  mater  or  exterior  division  of  the  proper 
cerebral  membrane,  with  the  choroid  plexus  or  interior  division, 
may  be  demonstrated  in  the  following  manner.  First,  the  pia  ma- 
ter may  be  traced  behind  and  below  the  posterior  extremity  of  the 
mesolobe  or  middle  band,  {(Smixo,  nXkoubii,  corpus  callosum,  der  bab 
ken,)  where  it  is  continuous  with  the  transverse  web  called  velum 
interpositum,  and  which  may  be  regarded  in  this  order  of  examina- 
tion as  the  first  part  of  the  central  division.  Secondly,  from  this 
point,  the  situation  of  the  velum  interpositum,  it  may  be  traced  for- 
wards on  both  sides  of  the  mesial  plane  into  the  lateral  ventricles, 
spread  over  the  surface  of  the  optic  thalamus  and  striated  eminence 
in  the  form  of  the  vascular  web  called  choroid  plexus,  the  right  half 
of  which  communicates  with  the  left  by  means  of  a similar  slip  of 
vascular'  membrane  lying  beneath  the  vault  {fornix),  and  behind 
the  anterior  pillars  of  that  body  at  the  spot  termed  Foramen  Mon- 
roianum.  Thirdly,  it  may  be  traced  over  the  geniculate  bodies  or 
posterior  eminences  of  each  thalamus  into  the  posterior-inferior  cor- 
nu, or  sinuosity  of  the  lateral  ventricle,  where  it  covers  the  great 
hippocampus.  Fourthly,  it  may  be  traced  at  the  angle  between  the 
cerebellum  and  medulla  oblongata,  or  what  is  named  the  bottom  of 
the  fourth  ventricle,  where  it  forms  a very  minute  choroid  plexus 
seldom  noticed  by  anatomists,  but  not  less  distinct,  and  which  may 
be  traced  up  the  fourth  ventricle  to  be  connected  with  the  velum 


694 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


interpositum  in  the  middle  ventricle,  and  with  the  lateral  portions 
of  the  hippocampus  on  each  side. 

Each  choroid  plexus,  or,  to  speak  more  accurately,  each  of  the 
divisions  of  the  choroid  plexus  now  enumerated,  may  be  shown  to 
be  mutually  connected,  and  to  form  parts  of  one  general  membrane, 
which  again  constitutes  the  inner  or  central  division  of  the  great 
membrane  of  which  the  pia  mater  forms  the  exterior.  Each  divi- 
sion of  the  choroid  plexus,  in  like  mannei*,  is  connected,  by  means 
of  minute  blood-vessels,  to  the  portion  of  the  figurate  cerebral  sur- 
face on  which  it  rests,  and  it  appears  to  perform  the  same  function 
of  sustaining  vessels  as  the  pia  mater  does  to  the  convoluted  sur- 
face. 

The  membranous  nature  and  appearance  of  the  choroid  plexus 
may  be  demonstrated  by  immersing  it  in  clear  water,  when,  by  a 
little  management  of  the  probe  and  foi’ceps,  it  may  be  spread  out 
exactly  like  the  pia  mater,  which  it  closely  resembles.  It  presents 
the  appearance  of  a thin  semitransparent  web,  one  surface  of  which 
is  smooth,  the  other  somewhat  flocculent,  and  the  substance  of  which 
appears  with  and  without  a glass  to  be  traversed  by  numerous  mi- 
nute vessels.  The  transparent  web,  which  forms  the  basis  or  ground- 
work of  this  membrane,  possesses  the  characters  of  very  close  fila- 
mentous tissue ; and  it  may  be  regarded  as  a filamento-vascular 
web.  Its  smooth  surface,  which  is  also  the  free  one,  is  manifestly 
a continuation  of  the  arachnoid  membrane.  Like  that  it  is  smooth, 
polished,  thin  as  the  finest  silver  paper,  and  it  may  be  raised  from 
the  more  filamento-vascular  basis  of  the  membrane  to  which  it  ad- 
heres. 

I am  now,  by  describing  the  characters  and  distribution  of  this 
membrane,  to  show  how  far  it  resembles,  and  how  far  it  is  unlike, 
the  perfect  serous  membrane. 

The  fine  inner  lamina  from  which  the  cerebral  surface  of  the 
dura  mater  derives  its  glistening  aspect,  I have  already  stated,  is  to 
be  regarded  as  the  outer  or  cranial  division  of  the  arachnoid  mem- 
brane. This  is  to  be  proved,  first,  by  its  anatomical  characters, 
and,  secondly,  by  its  distribution  and  transit. 

The  inner  or  free  surface  of  the  dura  mater  presents,  it  has  been 
already  said,  all  the  characters  of  the  free  surface  of  the  pia  mater, 
except  one,  the  facility  with  which  the  thin  pellicle,  which  gives  it 
these  characters,  can  be  detached.  This,  however,  is  derived  from 
the  want  of  filamentous  tissue  intermediate  between  the  fibrous  layer 


SEROUS  MEMBRANE. 


695 


of  the  dura  mater  and  the  pellucid  membrane;  and  the  latter  is 
thus  so  intimately  united  with  the  former,  that  it  is  difficult,  if  not 
impossible,  by  the  ordinary  means,  to  detach  them.  This,  however, 
is  no  more  a reason  for  regarding  this  pellucid  pellicle  as  the  same 
as  the  dura  mater,  than  the  intimate  adhesion  of  the  capsular  peri- 
cardium to  its  fibrous  coat,  or  of  the  peritonaeum  to  the  female 
ovaries,  is  for  regarding  the  membranes  as  part  of  these  organs. 
Immersion  in  boiling  water  and  maceration  produce  on  this  surface 
of  the  dura  mater  the  same  effects  as  on  the  free  surface  of  \he,  pia 
mater.  Lastly,  the  phenomena  of  morbid  processes  indicate  that 
these  surfaces  are  in  all  respects  similar ; and  if  the  thin  pellicle  on 
the  free  surface  of  the  pia  mater  is  entitled  to  separate  existence, 
that  on  the  free  surface  of  the  dura  mater  is  equally  so. 

The  continuity  of  these  two  divisions,  demonstrated  by  their  con- 
figuration, affords  proofs  of  the  same  description.  This  is  most 
easily  accomplished  by  tracing  the  dura  mater  from  those  points  at 
which  it  adheres  to  the  inner  surface  of  the  cranium,  to  those  at 
which  the  several  nerves  issue  from  that  cavity  by  the  cranial  holes. 
If  the  optic  nerves  be  attentively  examined  at  the  spot  where  they 
enter  the  optic  foramina,  the  dura  mater,  which  covers  the  bone 
around  these  holes,  is  found  to  go  a very  short  distance  into  them, 
to  stop  suddenly,  and  be  reflected  backwards,  in  anatomical  lan- 
guage, to  cover  the  nervous  trunks,  and  to  extend  along  the  pia 
mater.  This  reflected  portion  is  in  truth  the  arachnoid  membrane 
which  lines  the  dura  mater,  passing  from  it  along  the  nervous  chords 
to  form  the  free  surface  of  the  pia  mater.  In  like  manner,  if  the 
third  pair  or  oculo-muscular,  or  fifth  or  tergeminal  nerves  be  exa- 
mined at  the  openings  at  which  they  perforate  the  skull,  the  dura 
mater  is  found  adhering  firmly  round  their  several  mai'gins  to  the 
bone  by  its  outer  or  attached  surface,  while  its  inner  free  surface 
turns  back  on  the  nervous  chords,  and  is  thence  continued  over  the 
pia  mater.  In  short,  the  continuity  of  this  thin  transparent  mem- 
brane from  the  dura  mater  to  the  pia  mater  may  be  traced  at  each 
of  the  nervous  trunks  as  they  issue  from  the  brain  through  the 
cranial  apertures. 

Another  proof  of  a similar  description  is  derived  from  examin- 
ing the  free  or  lower  margins  of  the  falx  major  and  minor,  and  of 
the  horizontal  portion  of  the  dura,  mater,  {tentorium  cerebelli). 
First,  at  the  upper  or  convex  margin  of  the  great  falx,  where  the 
veins  pass  from  the  pia  mater  to  the  longitudinal  sinus,  it  is  not  dif- 


696 


GENERAL  AND  PATHOLOGICAL  ANATOJIY. 


ficult  to  trace  the  arachnoid  ineinbrane  from  the  pia  mater  along 
their  coats,  to  that  portion  of  the  dura  mater  which  forms  the  sinns, 
and  conversely,  from  the  falx  along  the  veins  to  the  free  surface  of 
the  pia  mater.  In  the  second  place,  the  lower,  or  concave  margin 
of  the  falx,  is  connected  at  the  bottom  of  the  middle  fissure  between 
the  hemispheres  to  the  pia  mater  on  each  side  by  thin  transparent 
filamentous  membrane,  which  is  in  truth  the  arachnoid  passing  from 
the  falciform  process  of  the  dura  mater  to  the  free  surface  of  the 
pia  mater,  covering  the  commutual  surfaces  of  the  hemispheres ; 
and  the  same  may  be  seen  at  the  lower  margin  of  the  small  or  ce- 
rebellic  falciform  process.  In  the  third  place,  at  the  inner  mar- 
gin of  the  transverse  portion  or  tentorium,  the  transparent  pellicle 
of  the  dura  mater  maybe  traced  passing  to  ihepia  mater  of  the  brain 
above,  and  of  the  cerebellum  below.  The  same  arrangement  may 
be  demonstrated  in  the  vertebral  cavity,  in  which  it  further  covers 
the  serrated  membrane,  {ligamentum  denticulatum).  In  short,  while 
the  dura  mater  is  proper  to  the  inner  surface  of  the  skull,  and  the 
pin  mater  to  the  surfaces  of  the  brain,  the  arachnoid  membrane  is 
common  to  both,  and  invests  not  only  the  free  surface  of  the  pia 
mater,  as  is  usually  stated,  but  the  inner  surface  of  the  dura  mater. 

The  arachnoid  has  a still  more  extended  distribution.  After  co- 
vering the  free  or  inner  surface  of  the  pia  mater.,  it  follows  the 
course  of  that  membrane  into  the  central  surface  of  the  brain,  and 
covers  the  upper  or  unadherent  surface  of  the  several  divisions  of 
the  choroid  plexus.  This  is  demonstrated  by  the  same  process 
by  which  the  continuity  of  the  plexus  with  the  pia  mater  is  esta- 
blished. 

From  the  foregoing  description  it  results  that  the  arachnoid 
membrane  possesses  in  arrangement  and  distribution  a great  re- 
semblance to  the  serous  membranes.  It  differs,  nevertheless,  in 
its  extreme  tenuity,  in  the  closeness  with  which  it  adheres  to  the 
collateral  tissues,  and,  as  will  afterwards  appear,  in  its  slight  dis- 
position, to  albuminous  exudation.  It  appears  to  contain  in  its 
structure  less  filamentous  tissue  than  the  pure  serous  membranes. 

I have  elsewhere,  in  treating  of  the  development  of  the  brain, 
had  occasion  to  speak  of  the  cerebral  membranes.  The  pia  mater 
in  the  twofold  form  now  described  exists  at  an  early  period  of  the 
ovum,  before  the  formation  of  the  brain  is  commenced.  It  is  then 
recognized  in  the  form  of  a very  vascular  membrane,  somewhat 
confused,  but  still  sufficiently  distinct  to  show,  that  in  the  centre 


SEROUS  MEMBRANE. — INFLAMMATION. 


697 


of  each  half,  the  cerebral  matter  afterwards  to  constitute  the  he- 
mispheres is  deposited  from  the  vessels  of  its  central  or  attached 
surface.  At  this  period  the  arachnoid  pellicle  cannot  be  distin- 
guished. It  is  only  when  a considerable  part  of  each  hemisphere 
is  formed  that  the  free  surface  of  the  pia  mater  can  be  shown  to 
be  covered  by  arachnoid  membrane.  This  may  be  stated  in  gene- 
ral terms  to  be  between  the  end  of  the  fifth  and  the  middle  of  the 
seventh  month,.  The  free  surface  of  the  dura  mater  begins  to  be 
perceptible  about  the  same  time. 

§ 4.  The  tunica  albuginea  of  the  testicle  may  be  here  mentioned  as 
a membrane  composed  of  fibrous- tissue,  embracing  the  gland,  and  a 
very  thin  pellucid  layer  outside,  without  intermediate  filamentous 
tissue, — a peculiarity  in  which  it  resembles  the  female  ovary. 

Section  II. 

The  serous  membranes  are  the  seat  of  a considerable  number  of 
morbid  processes,  which,  according  as  they  take  place  in  one  mem- 
brane or  another,  give  rise  to  several  of  those  diseases  which  it  is 
the  province  of  nosology  to  distinguish  and  of  medicine  to  treat. 
Most  of  these  processes  may  be  referred  to  inflammation  or  its  ef- 
fects, dropsy,  hemorrhage,  morbid  deposits,  and  new  growths. 

I.  Inflammation  occurs  in  serous  membrane  under  at  least 
two  forms,  acute  and  chronic.  The  anatomical  characters  of  the 
process  vary  according  to  its  acute  or  chronic  charactei*,  and  ac- 
cording to  the  physiological  peculiarities  of  the  affected  membrane. 
These  characters  it  is  perhaps  most  convenient  to  examine,  as  they 
appear  in  the  pleura,  pericardium,  and  peritonaeum,  in  which  they 
assume  their  most  perfect  form. 

§ 1.  When  inflammation  commences  in  a serous  or  diaphanous 
membrane,  the  first  change  which  is  observed  to  take  place  in  it,  is 
diminution  or  loss  of  its  transparent  and  glistening  appearance.*  It 
becomes  opaque,  dull,  and  in  some  instances  dry.  This  change  is 
very  well  seen,  not  only  in  the  pleura,  pericardium,  and  perito- 
naeum, but  in  the  arachnoid  membrane,  in  which  it  is  distinct  when 

* “ When  inflammation,”  says  Hunter,  “ takes  place  in  parts  that  have  a degree  of 
transparency,  that  transparency  is  lessened.  This  is  probably  best  seen  in  membranes, 
such  as  those  membranes  which  line  cavities  or  cover  bodies  in  those  cavities,  such  as 
the  pia  mater,  -where  in  a natural  state  we  may  observe  the  blood-vessels  to  be  verv 
distinct.” — 4to,  p.  281. 


698 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


other  traces  of  the  process  cannot  be  recognized.  It  is  from  this 
circumstance  that  dulness  of  the  arachnoid  denotes,  with  great  cer- 
tainty, serous  effusion  within  the  cerebral  cavities. 

§ 2.  At  the  same  time,  red  vessels  may  appear  either  in  isolated 
spots  or  over  a considerable  extent.  They  are  generally  arborescent 
or  parted  into  minute  ramifications.  Sometimes  they  consist  of  mi- 
nute red  lines,  radiating  from  a point  like  stars ; and  in  other  in- 
stances they  form  a confused  net-work  of  red  vessels,  interspersed 
with  bloody  points  and  spots,  amounting  occasionally  to  extrava- 
sation. These  vessels,  which,  though  placed  in  the  substance  of 
the  membranes,  gradually  approach  the  surface  as  the  process  ad- 
vances, are  not  newly  developed,  but  appear  to  be  the  colourless 
capillaries  of  the  sound  state  of  the  membranes  injected  with  red 
blood.  These  changes,  which  may  be  regarded  as  the  essence  of 
the  first  stage  of  inflammation  in  serous  membranes,  are  best  ob- 
served in  the  pleura,  pericai’dium,  and  peritonaeum.  In  these  they 
are  sometimes  so  intense  and  general,  as  to  give  the  membranes  a 
red  mottled  appearance,  and  prevent  the  observer  from  distinguish- 
ing the  subjacent  tissue. 

§ 3.  After  existing  for  some  time,  varying  in  different  circumstances 
(from  6 to  20  hours  in  the  pleura  and  peritonoeum^)  these  changes 
are  follow'ed  by  others,  which  may  be  regarded  as  their  effects. 
The  first  and  most  important  of  these  is  the  formation  of  a new 
fluid  at  the  free  or  unadherent  surface  of  the  membrane.  The  na- 
ture of  this  fluid  varies  according  to  the  stage,  and  perhaps  the  kind 
of  inflammation.  I shall  describe  first  that  which  takes  place  in 
the  commencement  of  the  acute  form. 

a.  The  capillary  injection  of  the  inflammatory  process  is  scarcely 
well  established  when  it  begins  to  cause  a semitransparent  fluid  to 
ooze  in  small  quantity  from  the  affected  points  of  the  surface  of 
these  membranes.  In  this  state  the  characters  of  the  fluid  can 
scarcely  be  determined.  In  a more  advanced  stage  of  the  process, 
when  it  is  abundant,  it  is  a straw-coloured,  homogeneous,  semi- 
transparent fluid,  which,  as  it  is  effused,  undergoes  spontaneous 
coagulation.  This  consists  in  part  of  the  fluid  assuming  a solid 
form  in  the  shape  of  a semifluid  jelly-like  layer  of  variable  thick- 
ness, with  a rough  honey-comb  surface  exteriorly,  where  it  is  in 
contact  with  the  membranes,  and  interiorly  with  thready  filaments 
mutually  interlacing,  and  more  or  less  consistent.  A thin  fluid 
portion  at  the  same  time  is  found  in  the  interstices  of  these  fila- 


SEROUS  MEMBRANE. — INFLAMMATORY  PRODUCTS.  699 

merits,  and  oozes  from  the  surface  of  the  coagulated  part.  These 
facts  are  easily  demonstrated,  by  examining  the  effused  matter 
while  still  recent,  and  while  the  process  of  coagulation  is  going  on, 
but  not  completed.  It  is  then  a soft,  spongy,  translucent  matter, 
of  a straw-yellow'  colour,  and  pulpy  gelatinous  consistence.  When 
removed  from  the  membrane  its  surface  is  rough  and  irregular, 
like  honey-comb,  and  marked  by  blood  spots  more  or  less  nume- 
rous, which  are  occasioned  by  the  forcible  rupture  of  the  minute 
vessels  of  the  membrane  passing  into  the  new  product ; while  se- 
rous fluid  trickles  from  it  and  falls  to  the  most  dependent  part  of 
the  cavity.  When  cut  or  torn  in  minute  pieces,  this  serous  fluid 
oozes  abundantly  from  the  sections ; and  the  observer  may  then 
remark  the  filamentous  and  cellular  disposition  of  the  solid  coagu- 
lated portions.  The  filaments  varying  in  size  cross  each  other  mu- 
tually, so  as  to  form  partitions  and  intermediate  cells,  but  without 
regular  order. 

The  matter  thus  effused  is  what  was  named  by  Hunter  coagulat- 
ing or  coagulahle  lymph,  in  consequence  of  its  property  of  sponta- 
neous coagulation.  It  is  often  mentioned  among  some  of  the  older 
anatomists  as  masses  of  liquid  fat  found  between  the  serous  mem- 
branes ; and  even  Dr  Cleghorn  speaks  of  it  in  this  manner.  Its 
property  of  coagulation  depends  chiefly  on  the  proportion  of  albu- 
men which  it  contains.  If  a mass  of  coagulahle  lymph  in  its  re- 
cent, straw-coloured,  and  translucent  state,  be  immersed  in  alcohol, 
it  instantly  becomes  shrivelled,  indurated,  of  a white  colour,  and 
perfectly  opaque ; and  the  same  changes  result  from  immersion  in 
dilute  acids  or  in  boiling  fluids.  It  also  becomes  much  tougher 
and  firmer.  From  this  circumstance  it  has  been  denominated  by 
the  foreign  authors  albuminous  exudation.  Of  its  soft  state,  when 
recently  effused,  it  is  of  the  utmost  importance  for  the  physician  to 
be  aware,  in  consequence  of  the  fact  which  I have  now  verified  se- 
veral times,  that  in  the  pleura  it  communicates  to  the  ear  the  same 
stethoscopic  and  percussive  phenomena  which  arise  from  the  pre- 
sence of  fluid. 

b.  After  its  first  coagulation  this  substance  undergoes  other  changes 
which  are  highly  important  in  a pathological  relation.  As  the  dia- 
phanous membranes  are  at  all  times  mutually  applied,  a very  com- 
mon effect  of  this  effused  substance  and  its  coagulation  is  to  connect 
the  corresponding  points  more  or  less  firmly.  The  process  by 
which  this  is  accomplished  was  understood  by  Hunter  and  Balllie, 


700 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


and  may  be  stated  in  the  following  terms.  As  the  lymph  is  effused 
and  separated  into  clot  or  coagulable  part  and  fluid,  the  former  is 
observed  to  be  soon  penetrated  by  minute  red  vessels,  which  may 
be  demonstrated  by  injection,  and  the  existence  of  which  is  also 
proved  by  the  fact  above-mentioned,  that  the  surface  of  a piece  of 
detached  lymph  is  marked  by  numerous  blood-spots,  occasioned  by 
the  rupture  of  the  elongated  capillaries  of  the  inflamed  membrane. 
These  vessels  may  be  traced  from  the  latter  into  the  extravasated 
substance,  in  which  they  are  observed  to  ramify.  Red  spots,  like 
effused  blood,  also  appear  through  the  substance  of  the  lymph,  and 
in  the  course  of  a few  hours  these  are  discovered  to  be  new  vessels. 

As  this  process,  which  constitutes  the  organization  of  the  lymph, 
advances,  the  penetrating  vessels  become  more  numerous,  and  the 
lymph  becomes  more  firmly  attached  to  the  inflamed  surface  of  the 
membrane.  At  the  same  time  the  fluid  part  of  the  exudation  oozes 
away  and  drops  down  to  the  most  dependent  points  of  the  cavity, 
or,  if  not  abundant,  it  is  absorbed.  In  the  former  case  it  forms  the 
serous  or  sero-purulent  fluid,  occasionally  found  in  considerable 
quantities  within  the  pleura  and  peritoncEum.  Meanwhile  the  al- 
buminous portion  becoming  firmer  and  something  opaque,  the  soft, 
pulpy,  gelatinous,  translucent,  straw-coloured  substance  is  gradually 
converted  into  a firm,  white,  opaque  body,  uniting  more  or  less  ex- 
actly the  corresponding  surfaces  of  the  membrane.  The  new  ves- 
sels of  its  interior  substance  at  the  same  time  contract,  and  ulti- 
mately convey  only  colourless  fluid.  The  substance  thus  rendered 
organic  and  the  seat  of  an  incessant  process  of  exhalation  and  ab- 
sorption, is  termed  membrane  of  adhesion  (^concretio,  concrementum,') 
or  false  membrane.  The  process  by  which  it  is  formed  is  termed 
union  by  adhesion,  or  simply  adhesion. 

These  phenomena  are  most  commonly  observed  in  the  pleura, 
pericardium,  and  peritoncBum,  in  each  of  which  they  are  modified 
according  to  the  local  peculiarities  of  the  membrane. 

In  the  pleura  it  appears  in  the  form  of  a broad  layer,  variable  in 
thickness,  extending  between  the  convex  surface  of  the  pulmonic  h 
and  the  concave  surface  of  the  costal  pleura ; or  it  may  occur  in  :j 
the  spaces  between  the  lobes ; (interlobular  pleurisy  of  Laennec)  ; i 
or  it  may  be  stretched  between  the  j)leura  of  the  inferior  concave 
surface  of  the  lung  and  that  of  the  thoracic  or  convex  surface  of 
the  diaphragm.  When  the  lung  is  affected  by  tubercles  or  tuber- 
cular excavations,  it  often  occurs  in  the  form  of  short  membranous 


SEROUS  MEMBRANE. INFLAMMATORY  PRODUCTS.  701 

slips,  and  very  generally  as  a.  membranous  capsule  covering  the 
apex  of  the  lung,  and  connecting  it  to  the  thoracic  pleura. 

In  the  pericardium  the  constant  motion  of  the  heart  modifies  the 
appearance  of  the  albuminous  exudation.  As  this  motion  prevents 
during  coagulation  the  exact  apposition  of  the  surfaces  of  the  cap- 
sular and  cardiac  divisions  of  the  membrane,  the  most  prominent 
parts,  or  those  which  least  change  relation  only  adhere.  This 
forms  the  irregular  laminated  processes  mentioned  by  Baillie  as 
giving  the  appearance  of  lace-work  ; and  if  the  capsule  be  separated 
from  the  heart  in  this  stage  of  the  process,  it  gives  the  result  no- 
ticed by  Laennec,  who  compares  it  to  the  appearance  produced  by 
the  sudden  separation  of  two  pieces  of  slab  united  by  a thick  layer 
of  butter.  At  a later  period  this  disunion  will  afford  the  calf-sto- 
mach surface  {caillehottee  ; honnet  de  veau'),*  which  may  be  regard- 
ed as  the  link  connecting  the  orgauizable  state  of  the  deposition 
with  that  in  which  it  forms  an  adherent  tissue. 

In  the  peritonaeum  it  takes  place  chiefly  along  the  line  of  one 
portion  of  ileum  with  another,  and  between  the  prominent  points 
of  these  and  the  omentum,  or  the  muscular  portion  of  the  mem- 
brane. In  some  instances  every  fold  almost  of  ileum  is  connected 
with  some  other,  and  the  whole  are  matted  together  by  long  trian- 
gular prisms  of  lymph,  generally  opaque,  of  a lemon-yellow-colour, 
and  of  a pulpy  or  gelatiniform  consistence. 

Albuminous  exudation  or  lymph  is  much  less  frequently  found 
between  the  surfaces  of  the  arachnoid  membrane.  That  it  is  ac- 
tually secreted  by  tliis  membrane,  however,  is  well  established. 
Dr  Stark  records  three  cases  in  which  coagulated  lymph  was  found 
between  the  dura  and  pia  mater ^ and  round  the  membranous  co- 
verings of  the  medulla  oblongata  awdi  spinal  chord.f  ‘One  example 
of  this  exudation  is  delineated  by.  Baillie  and  Hooper  represents 
three  in  which  he  traces  its  progress  from  simple  inflammation  to 
organized  membrane. § Instances  of  albuminous  exudation  on  the 
surface  of  tne  arachnoid  are  also  mentioned  by  Tacheron,  Andral, 
and  Dr  Abercrombie.  ||  In  the  body  of  a woman  who  died  with 
symptoms  of  intense  coma,  I found  a thin  but  distinct  albuminous 
deposit  on  the  free  surface  of  the  arachnoid,  extending  from  the 

* Laennec,  Observ.  1,  2,  3,  4,  and  Art.  u.  Obs.  4. 

t The  Works  of  the  late  William  Stark,  M.  D,  Lond.  1788.  Part  iv.  p.'  69. 

+ Plate  iv.  Fascic.  X.  g Plates  i.  and  ii. 

II  Pathological  and  Practical  Researches,  &c.  p.  51 56 60. 


702 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


optic  commissure  to  the  posterior  margin  of  the  annular  protube- 
rance. It  was  less  firm  and  more  translucent  than  in  the  pleura 
01’  peritonaeum,  hut  presented  in  other  respects  the  usual  proper- 
ties. This  albuminous  deposit  I have  seen  take  place  over  the  su- 
perior and  lateral  regions  of  the  arachnoid  in  adults,  though  it  is 
much  less  frequent,  spontaneously,  than  in  consequence  of  external 
injury.*  Albuminous  exudation  I have  likewise  observed  in  the 
arachnoid  membrane  of  the  base  and  lateral  regions  of  the  brain  in 
children  who  have  died  with  symptoms  of  meningeal  inflammation, 
or  water  in  the  brain.  Similar  depositions  have  been  remarked  in 
various  regions  of  the  arachnoid  by  Parent-Duchatelet,  Martinet, 
Bayle,  and  others. 

c.  Baillieand  most  other  observers  notice,  besides  coagulating  lymph 
or  albuminous  exudation,  a serous  fluid,  limpid,  yellowish,  reddish, 
or  brownish,  according  to  circumstances.  Though  this  fluid  has 
been  supposed  to  be  derived  immediately  from  the  blood,  there  is 
no  doubt,  that  it  is  the  serous  or  watery  portion  of  the  morbid  ex- 
udation, from  the  surface  and  interstices  of  which  it  may  be  seen 
trickling.  The  red  or  brown  tint  it  derives  from  blood  issuing 
from  the  newly  formed  capillaries  opened  by  laceration  of  the  lymph 
from  the  membrane.  Shreds  of  lymph  are  at  the  same  time  found 
floating  in  it.  This  is  most  generally  seen  in  the  pleura  and  pe- 
ricardium. 

I have  already  stated  that  the  exudation  of  inflamed  serous  mem- 
brane owes  its  coagulability  to  the  presence  of  albuminous  matter  ; 
and  indeed  upon  the  proportion  of  this  ingredient  the  process  of 
coagulation  depends.  In  certain  instances,  in  which  the  inflamma- 
tory process  is  believed  to  be  less  genuine  and  energetic,  this  prin- 
ciple is  so  scanty  that  coagulation  is  partial  and  imperfect;  and  in- 
stead of  a uniform  layer  of  lymph  between  the  mutual  surfaces, 
each  presents  a series  of  loose  shreds  and  patches,  with  a conside- 
rable quantity  of  reddish,  or  whitish,  semi-opaque  fluid  in  the  de- 
pendent part  of  the  cavity.  This  constitutes  the  link  between  the 
albuminous  and  the  purulent,  sero-purulent,  or  serous  products  of 
inflammation  in  these  membranes. 

§ 4.  Examined  more  minutely  we  find  that  the  fluid  varies  in  its 
proportion  of  albumen  in  different  membranes,  and  according  to  the 

* Clinical  Report  of  Edinburgh  Royal  Infirmary  for  1836-1837.  Edinburgh  Me- 
dical and  Surgical  .Tournal,  Vol.  xlvii.  p.  305. 


SEROUS  MEMBRANE. — PURULENT  SECRETION. 


703 


form  of  the  inflammatory  process.  These  variations  may  be  refer- 
red generally  to  two  heads,  puriform  and  serous  secretions. 

The  varieties  of  puriform  secretion  may  be  classed  under  the 
heads  of  sero-purulent,  pm’iform,  and  purulent. 

The  sero-purulent  is  often  connected  with  the  albuminous,  from 
which  it  is  separated  during  the  process  of  coagulation.  It  consists 
chiefly  of  serous  fluid  with  minute  granules  of  albuminous  matter, 
which  subside  to  the  bottom  and  leave  the  supernatant  liquor  like 
whey  or  chalk- water.  It  always  contains  flakes  of  lymph.  It  takes 
place  in  pleuritic  and  peritoneal  inflammation,  acute  and  chronic, 
and  is  generally  found  in  the  dependent  part  of  the  cavity,  e.  g.  in 
the  posterior  part  of  the  chest,  and  in  the  lumbar  and  hypogastric 
fossce  in  the  peritonaeum. 

The  puriform  fluid  of  serous  membranes  consists  of  serons  fluid, 
with  an  opaque  and  thicker  matter  not  coagulable  in  mass  blended 
with  it  more  equably  than  in  the  last  case.  The  granular  matter 
is  less  abundant  or  entirely  wanting ; and  the  opaque  milky  fluid  is 
not  so  easily  separable  as  in  the  sero-purulent  fluid.  Though  it  is 
often  associated  with  the  albuminous,  and  contains  flakes  of  lymph, 
yet,  as  little  lymph  is  found  on  the  surface  of  the  membranes,  and 
as  the  quantity  of  the  latter  is  often  in  the  inverse  ratio  of  the  quan- 
tity of  puriform  fluid,  it  may  be  regarded  as  less  nearly  allied  to  the 
pure  albuminous  inflammation  than  the  sero-purulent.  Both  are 
to  be  regarded  as  abortive  efforts  to  eflfect  albuminous  exudation. 

The  puriform  secretion  occurs  in  all  the  serous  membranes,  but 
is  most  frequent  in  the  peritonaeum.  It  is  in  particular  very  com- 
mon in  that  form  of  peritoneal  inflammation  which  occurs  in  the 
persons  of  women  in  childbed ; and  Hunter,  who  was  aware  of  the 
fact,  states  it  as  an  instance  of  the  combination  of  the  adhesive  with 
the  suppurative  inflammation, — a circumstance  to  which  he  ascribes 
the  unfavourable  issue  of  such  cases.*  It  is  occasionally  the  com- 
bination, and  sometimes  the  substitution  of  the  suppurative  for  the 
adhesive  process.  This  is  amply  confirmed  by  the  necroscopic  ap- 
pearances of  peritoneal  inflammation  in  puerperal  females,  in  which 
every  shade  of  morbid  eflfusion  is  seen,  from  albuminous  lymph, 
with  separation  of  proper  serous  fluid,  to  puriform  or  purulent  col- 
lection. 

* “ This  mixing  of  the  suppurative  with  the  adhesive,  or  the  hurrjdng  on  of  the  sup- 
purative, 1 have  frequently  seen  in  the  abdomen  of  women  who  have  been  attacked 
with  the  peritoneal  inflammation  after  child-birth,  and  which,  from  these  circumstances 
became  the  cause  of  their  death.” — On  the  Blood,  &c. 


704 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Genuine  purulent  fluid,  as  it  is  represented  by  pathological  au- 
thors,— a white,  or  cream-coloured,  opaque,  and  homogeneous  fluid, 
— is  another  product  of  inflammation  of  serous  membranes.  Though 
always  combined  with  more  or  less  albuminous  exudation,  which  is 
found  in  loose  irregular  patches  on  the  membrane,  and  in  the  form 
of  shreds  and  flakes  in  the  fluid,  it  is  more  uniform  in  composition 
than  the  puriform,  being  destitute  of  the  granular  matter,  and  not 
separating,  when  allowed  to  rest,  into  thin  and  solid  matter.  It  oc- 
curs in  chronic  pleurisy,  (^empyema,)  in  pericardial  inflammation  as 
an  effect  of  the  acute,  and  in  peritonitis,  acute,  subacute,  and  chro- 
nic, especially  the  puerperal. 

It  was  at  one  time  believed  that  genuine  purulent  matter  could 
not  be  formed  in  these  membranes,  unless  as  an  effect  of  the  pre- 
liminary process  of  ulceration.  Instances  of  purulent  collections 
in  the  chest  without  ulceration  of  the  pleura,  and  of  purulent  matter 
in  the  abdomen  without  breach  in  the  peritonseum,  might  have  led 
pathological  writers  to  the  inference,  that  suppuration  may  occur 
in  a serous  membrane  without  ulceration,  and  that,secretion  of  puru- 
lent matter  is  one  of  the  effects  of  simple  inflammation  of  serous 
tissue.  The  truth  of  this  fact,  however,  appears  not  to  have  been 
established  before  the  time  of  V/illiam  and  John  Hunter,  the  last 
of  whom  notices  it  as  a point  not  previously  ascertained.  Speak- 
ing of  the  transition  or  gradual  change  from  coagulable  lymph  to 
purulent  fluid,  he  infers  “ that  suppuration  takes  place  in  serous 
surfaces  without  a breach  of  solids  or  dissolution  of  parts,”  men- 
tions it  as  a circumstance  “ not  commonly  allowed,”  and  considers 
this  suppuration  as  the  effect  of  a more  advanced  stage  of  the  pro- 
cess than  that  which  gives  rise  to  effusion  of  lymph,  and  union  by 
adhesion.  Of  this  fact,  he  informs  us,  he  first  became  aware  in 
1749  and  1750,  when,  in  the  inspection  of  a young  subject,  the 
left  side  of  the  chest  was  found  to  contain  a considerable  quantity 
of  purulent  matter  without  breach  of  the  pleura  or  surface  of  the 
lungs ; and,  at  the  same  time,  it  was  regarded  by  Dr  Hunter  and 
Mr  Samuel  Sharpe  as  a new  fact.*  It  has  since  been  often  ob- 
served both  in  the  pleura  and  peritonseum ; and  as  such  is  men- 
tioned by  William  Hunter,f  Baillie,  Black,  and  Willan.  It  is,  in 
truth,  seen  almost  daily  by  those  conversant  in  morbid  anatomy. 

* Treatise  on  Inflammation,  &c.  p.  379.  Note. 

+ “ Another  kind  of  pui  is  that  which  is  formed  without  any  apparent  breach  or 
dissolution  of  the  solids,  and  therefore  is  only  a sort  of  inspissated  serum,  or  an  inflam- 


SEROUS  MEMBRANE. — SUBSEROUS  DEPOSITS. 


705 


The  purulent  fluid  in  this  case  and  many  others  is  secreted  partly 
from  the  surface  of  the  inflamed  membrane,  partly  from  the  orga- 
nized layer  of  lymph,  partly  from  both.  In  the  first  case,  the  pu- 
riform  or  purulent  fluid  is  secreted  directly  by  the  capillaries  of 
the  inflamed  membrane.  In  the  second,  it  is  derived  from  those 
of  the  organized  false  membranes,  which  assume  tlie  suppurative 
action.  In  the  third,  both  sets  of  vessels  are  concerned.  These 
facts  are  demonstrated  in  instances  of  chronic  pleurisy,  and  of  chro- 
nic inflammation  of  the  periton(Bum. 

§ 5.  A second  eflfect  of  inflammation  of  the  diaphanous  membranes 
is  efi’usion  or  secretion  of  fluid  in  the  subserous  filamentous  tissue. 
When  the  arachnoid  membrane  is  inflamed  the  delicate  filamentous 
tissue  which  connects  it  to  the  pia  mater  is  almost  invariably  dis- 
tended with  serous  fluid,  more  or  less  transparent.  This  change 
makes  the  arachnoid  membrane  look  as  if  it  were  raised  or  detached 
from  the  pia  mater  by  the  interposition  of  a transparent  or  slightly 
opaque  gelatinous  matter  uniformly  spread  between  them.  If  a 
puncture  or  incision,  however,  be  made,  a small  portion  only  trickles 
from  it,  being  that  which  is  exposed  to  the  immediate  incision. 
The  fluid  of  the  contiguous  parts  does  not  escape, — a circumstance 
which  with  inspection  shows  that  it  is  contained  in  the  interstices 
formed  by  the  mutual  crossing  of  the  filaments  of  the  subserous 
tissue.  In  this  manner  and  in  the  same  situation  albuminous  fluid 
may  be  efiused,  especially  at  the  base  of  the  brain.  In  pleurisy 
this  eflfusion  is  less  common,  unless  the  pulmonic  tissue  is  at  the 
same  time  inflamed, — a peculiarity  which  appears  to  depend  on  the 
intimate  union  between  the  pleura  and  lungs.  It  nevertheless  takes 
place  and  dissects  the  pleura  from  the  substance  of  the  lungs.  In  in- 
flammation of  the  pericardium  it  takes  place  beneath  the  cardiac  fold 
of  the  membrane,  and  occasionally  assumes  the  form  of  minute  ab- 

matory  exudation.  We  occasionally  meet  mth  collections  of  this  kind  in  all  the  na- 
tural internal  canties  of  the  body.  I have  seen  it  in  great  quantity  in  the  carity  of 
the  abdomen  or  of  the  peritonceum,  in  that  of  the  thorax  or  of  the  pleura,  and  in  the 
pericardium,  where  there  was  no  visible  suppuration,  ulceration,  or  dissolution  of  the 
solids,  or  any  part  of  the  surface  all  round.  This  kind  of  pm  is  generally  thinner  than 
that  of  an  abscess  ; and  the  containing  surface  is  more  or  less  covered  with  a glutinous 
concretion,  or  slough  of  the  same  colour  as  the  fluid,  in  some  parts  adhering  very 
loosely,  in  others  so  firmly,  that  it  can  hardly  be  rubbed  off ; but  still  the  surface 
covered  by  these  sloughs  is  without  ulceration  or  loss  of  substance.” — Medical  Obser- 
vations and  Inquiries,  Vol.  ii.  p.  61. 

BailUe,  Morbid  Anatomy,  passim. 

Black,  Clinical  and  Pathological  Reports.  Newiy,  1819. 

Willan,  Reports  on  the  Diseases  of  London,  1797.  P.  186.  8vo  Edition. 


TOG 


GENERAL  AND  PATHOLOGICAL  ANATOMV. 


scesses  in  the  subserous  tissue  and  on  the  surface  of  the  cardiac  fibres. 
In  inflammation  of  tbe  peritoneeum  it  is  more  common  ; and  careful 
inspection  may  detect  effusion  below  the  intestinal,  and  more  distinct- 
ly in  some  instances  below  the  muscular  peritonaeum.  In  this  situa- 
tion, indeed,  may  be  found  patches  and  minute  deposits  of  purulent 
fluid,  not  only  in  the  ordinary  forms  of  peritonaea]  inflammation, 
but  in  that  which  takes  place  in  the  persons  of  puerperal  women. 

§ 6.  A third  change  mentioned  as  a consequence  of  inflammation  in 
serous  membranes  is  inordinate  thickness  and  some  degree  of  pulpi- 
ness.* On  this  point  there  is  among  pathologists  some  difference 
of  opinion.  The  occurrence  of  thickening  is  contradicted  by  Laen- 
nec,  who  denies  that  inflammation  produces  thickening  of  the  pleura, 
and  contends  that  observers  have  been  misled  by  morbid  deposits  on 
its  surface,  or  the  formation  of  new  membranes.  Without  doubt- 
ing the  discernment  or  candour  of  this  pathologist,  I must  remark, 
that,  as  Baillie  expressly  mentions  thickening  as  a consequence  of 
inflammation  in  the  pleura,  peritoneum,  and  mesentery,  and  as  this 
is  confirmed  in  regard  to  the  peritoneum  by  the  testimony  of  Pem- 
bertonf  and  Black,|  the  question  resolves  itself  into  one  of  indivi- 
dual observation.  If,  in  some  instances  of  acute  inflammation  of 
serous  surfaces,  thickening  is  not  recognized,  there  are  few  in  which 
the  chronic  form  of  the  process  affects  the  pleura,  pericardium,  and 
peritonaeum,  without  more  or  less  thickening  of  the  membrane. 
The  appearance  of  this,  indeed,  may  arise  from  effusion  into  the 
subserous  filamentous  tissue ; but  in  cases  of  chronic  inflammation 
the  membrane  itself  appears  to  be  not  only  thicker,  but  harder  and 
firmer  than  natural.  Does  this  change  depend  on  effusion  of  lymph 
into  its  component  tissue,  or  development  of  vessels  which  are  loaded 
with  various  fluids  ? The  thickening  to  which  I allude  is  mostly 
at  the  attached  surface ; and  I think  that  in  that  situation  it  de- 
pends on  the  effusion  of  lymph  into  the  subserous  cellular  tissue. 
In  chronic  peritonitis  I have  observed  the  attached  surface  of  the 
membrane  manifestly  loaded  with  extravasated  matter  in  the  inter- 
stices of  the  filamentous  tissue.  What  are  the  cases  in  which  the 
serous  membranes  become  pulpy  or  softer  than  natural,  while  they 
are  also  thickened  ? On  these  points  accurate  information  is  still 
wanting. 

On  the  other  hand,  it  must  be  allowed,  that  the  conditions  usually 
mentioned  as  examples  of  thickening  of  the  serous  membranes,  are, 

* Baillie’s  Morbid  Anatomy,  p.  54,  127,  and  200,  in  reference  to  the  mesentery. 

I On  the  Abdominal  Viscera.  + Clinical  and  Pathological  Reports,  &c. 


SEROUS  MEMBRANE. — ULCERATION. 


707 


in  truth,  new  deposits  on  their  free  surface.  A deposit  of  lymph 
which  has  become  contracted  and  indurated,  or  even  cartilaginous, 
a deposit  of  tubercular  matter,  and  patches  of  cartilage  are  formed 
on  the  free  surface  of  the  membrane ; and  though  they  appear  to 
render  it  thicker,  yet  are  they  adventitious  and  easy  removable  by 
dissection,  after  which  the  free  surface  of  the  membrane  comes  into 
view. 

§ 7.  The  next  effect  of  the  inflammatory  process  in  serous  membranes 
is  destruction  of  their  tissue  by  ulceration.  Though  this  may 
happen  in  the  acute  form  of  the  disease,  it  is  not  common.  But 
after  it  has  subsisted  for  some  time,  one  or  more  points  of  the  mem- 
brane begin  to  be  affected  by  the  ulcerative  process,  which  at  once 
spreads  superficially,  and  penetrates  its  substance.  The  manner  in 
which  this  takes  place  is  invariably  by  the  inflammatory  process 
affecting  the  subserous  tissue,  and  causing  their  suppuration  in  a 
circumscribed  point.  The  serous  membrane  being  no  longer  sup- 
ported at  this  point,  gives  way  sometimes  in  round  irregular  patches, 
sometimes  in  ragged  linear  fissures.  This  process  is  not  equally 
common  in  all  the  serous  membranes.  It  is  most  usual  in  the 
pleura,  pulmonic  and  costal,  and  in  the  muscular  peritonaeum. 

By  some  pathologists,  and,  if  I do  not  misunderstand  him,  by 
Hunter,  ulceration  is  ascribed  to  pressure  exercised  by  purulent 
matter;  and  thus,  indeed,  this  author  explains  the  tendency  which 
collections  of  matter  betray  to  proceed  towards  the  surface.  The 
pressure  of  such  agents,  doubtless,  operates  as  an  irritating  cause, 
and  may  therefore  produce  what  Hunter  terms  ulcerative  inflamma- 
tion. In  several  examples,  however,  ulceration  may  occur  as  a 
direct  effect  of  the  inflammatory  process,  without  the  formation  of 
matter  sufficient  by  pressure  to  cause  destruction  of  the  tissue ; and 
in  such  circumstances  I have  in  general  traced  it  to  previous  sup- 
puration of  the  subserous  tissue,  as  already  mentioned.  In  cases 
of  empyema  and  chronic  peritonitis,  especially  the  puerperal  form, 
in  which  this  ulceration  is  not  unfrequent,  both  causes  may  be  in 
operation.  But  even  in  the  interesting  case  of  peritoneal  inflam- 
mation given  by  Hunter  to  illustrate  the  nature  of  what  he  terms 
the  relaxing  process,  it  is  impossible  to  doubt,  that,  before  the  mus- 
cular peritonaeum  was  detached  in  the  shreds  and  fragments  in 
which  it  was  found  on  inspection,  inflammation  and  suppuration  of 
the  subserous  filamentous  tissue  had  taken  place.*  In  short,  from 

* Treatise  on  the  Blood,  &c.  Part  ii.  Chap.  vi.  Sect.  vi.  p.  461.  4to. 


708 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  cases  recorded,  and  from  several  which  I have  examined  per- 
sonally, I infer  that  ulceration  of  the  serous  tissue  is  always  pre- 
ceded by  inflammation  and  suppuration  of  the  subserous ; that  the 
attachment  of  the  former  being  thus  destroyed,  its  vitality  is  im- 
paired, and  its  cohesion  thereby  weakened ; and  that  it  gives  way 
rather  in  the  manner  of  laceration  than  genuine  ulceration. 

§ 8.  Observation  has  not  yet  determined  whether  gangrene  be  an 
effect  of  inflammation  of  the  serous  tissue.  That  it  is  occasionally  in- 
volved in  this  process  I infer  fi'om  seeing  the  pleura  in  gangrene  of 
the  lungs,  and  the  pcritonaum.  in  that  of  the  bowels,  soft,  black,  or 
greenish,  shreddy,  and  lacerable.  But  it  is  still  uncertain  whether 
primary  inflammation  of  a serous  tissue  exclusively  may  terminate 
in  mortification  of  that  membrane.  With  this  process  ulceration 
with  bloody  effusion  or  blood-coloured  patches  must  not  be  con- 
founded. Bichat  states,  that  in  numerous  bodies  which  he  inspect- 
ed, he  met  with  gangrene  of  the  peritoncEum  only ; and  that  he 
never  witnessed  an  instance  of  this  change  either  in  the  arachnoid 
membrane,  in  the  pleura^  in  the  pericardium,  or  in  the perididymis* 

On  the  surface  of  the  lungs  there  is  occasionally  observed  a spe- 
cies of  gangrene,  circumscribed  and  limited  in  extent.  A patch, 
dark  coloured  and  dead,  of  a shape  nearly,  sometimes  exactly  cir- 
cular, is  formed  at  the  surface,  that  Is,  the  pleural  surface  of  the 
lung.  The  size  of  these  patches  varies  from  the  size  of  a sixpenny 
piece  or  a shilling  to  a crown  piece.  The  patch  is  in  certain  cases 
observed  still  adherent,  though  black  and  dead.  In  other  in- 
stances it  has  dropped  off,  leaving  a cup-like  cavity,  pretty  exactly 
circular  in  outline,  regularly  hollowed  out  in  the  substance  of  the 
lung,  which  is  red  but  otherwise  natural  and  free  from  appearance 
of  gangrene. 

In  this  lesion,  which  I have  described  as  circumscribed  gangrene 
of  the  lungs,  the  pleura  is  affected  by  gangrene ; but  whether  pri- 
marily, or  only  in  connection  with  the  substance  of  the  lung,  it  is 
impossible  to  determine.  The  portions  so  affected  appear  exactly 
as  if  they  had  been  destroyed  by  the  direct  application  of  the  hot 
iron,  or  touched  by  a portion  of  caustic  potass. 

This  circumscribed  form  of  gangrene  of  the  pleura  and  surface 
of  the  lungs  is  sometimes  associated  with  diffuse  gangrene  in  the 
deep-seated  parenchyma  of  the  oi’gan.j 

* Anat.  Generate,  Tome  iii.  p.  517. 

t Cases  and  Observations  illustrative  of  the  Nature  of  Gangrene  of  the  Lungs.  I?y 
David  Craigie,  M.  D.,  &c.,  Edinburgh  Medical  and  Surgical  Journal,  Vol.  Ivi.  p.  !■ 
Edinburgh,  1841. 


SEROUS  MEMBRANE. — SEROUS  EFFUSIONS. 


709 


§ 9.  The  second  general  head  of  secretions,  or  those  termed  se- 
rous^ have  been  long  received  as  the  distinctive  character  of  the  dis- 
orders named  dropsies ; {Hyclropes.) 

To  the  influence  of  inflammation  or  capillary  injection  in  causing 
efiusion,  extravasation,  or  secretion  of  serum,  I have  already  in 
part  alluded.  In  no  texture  is  this  more  conspicuous  than  in  the 
serous  or  transparent.  The  mechanism  of  this  process  it  is  perhaps 
not  very  easy  to  explain  satisfactorily,  unless  by  referring  it  to  the 
same  principles  to  which  I have  already  referred,  the  ordinary  al- 
buminous and  purulent  exudations.  I shall  attempt,  however,  to 
state  as  briefly  as  possible  the  ascertained  facts  which  tend  to  esta- 
blish the  general  conclusion, — that  inordinate  accumulation  of  se- 
rous fluid  from  the  free  surface  of  the  diaphanous  membranes  is  a 
frequent  result  of  a process  of  capillary  congestion,  or  even  of  in- 
flammation. 

I have  already  stated  that  the  serous  membranes  in  general  are 
understood  to  be  the  seat  of  a process  of  incessant  exhalation  and 
resorption.  This  may  be  regarded  as  demonstrated  in  the  case  of 
the  pleura,  pericardium,  peritonceum,  and  perididymis,  by  the  ex- 
periments of  Haller,  Bichat,  and  others ; and  of  the  arachnoid,  the 
same  as  presumed  from  analogy.  The  fluid  thus  secreted,  though 
in  the  healthy  state  very  scanty,  is  distinctly  albuminous.  This 
may  be  regarded  as  demonstrated  by  the  rude  experiments  even  of 
Hewson  and  Bichat.  The  difficulty  in  the  healthy  state  of  obtain- 
ing a quantity  sufficient  for  analysis  led  Berzelius  to  examine  that 
of  hydrocephalus,  which  he  supposes  makes  a nearer  approach  to 
the  normal  condition  than  the  others ; and  of  this  he  found  1000 
parts  to  contain  1.66  of  albuminous  matter,  with  salts  of  potass  and 
soda,  and  some  animal  matter  combined  with  lactate  of  soda.* 
This  result  is  confirmed  by  the  researches  of  Bostock  and  Marcet, 
which  show  that  though  some  miico-extractive  matter  is  present, 
albumen  forms  tbe  chief  part  of  the  solid  contents  of  the  serum  of 
the  blood  and  the  fluids  of  the  serous  membranes.  Lastly,  Mar- 
cet, who  examined  all  the  dropsical  fluids,  found  that  they  contain 
coagulable  matter ; but  that  those  of  the  pleura,  pericardium,  and 
peritonaeum,  contain  much  more  than  the  arachnoid,  and  that  of 
hydrocele  most  of  all.f 

The  inordinate  augmentation  of  these  fluids  varies  in  degree, 

* General  Views  of  the  Composition  of  Animal  Fluids.  By  J.  Beizeliiis,  M.  D., 
&c.  Med.-Chir.  Transactions,  Vol.  iii.  251. 

•f-  MediGO-Chirurg.  Trans.  Vol.  ii.  p.  381. 


710 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


from  a few  ounces  to  several  pints  ; and  it  varies  according  to  the 
site  of  the  membrane  from  which  it  is  effused.  Thus  the  fluid  se- 
creted by  the  arachnoid  membrane  may  not  amount  to  above  half 
an  ounce,  or  at  most  to  two  or  three  ounces,  which  is  to  be  re- 
garded as  a great  quantity.  In  some  recorded  instances  it  is  said 
ratber  vaguely  to  amount  to  six.  The  fluid  secreted  by  the  peri- 
cardium may  not  be  above  one  ounce,  rarely  exceeds  two  or  three, 
and  in  a few  instances  only  amounts  to  six,  eight,  or  ten.  In  the 
pleura,  on  the  contrary,  it  may  amount  to  three,  four,  or  five  pints 
or  quarts ; and  in  the  peritoneum  has  been  known  to  amount  to 
several  gallons. 

The  quality  of  this  fluid  varies.  That  of  the  arachnoid  is  limpid 
and  colourless,  like  clear  water,  with  a slight  saline  taste,  and  con- 
tains traces  of  albumen.  In  the  pericardium  it  is  light  coloured 
and  semitransparent.  In  the  pleura  it  may  be  straw-yellow  and 
semitransparent,  but  is  more  frequently  reddish,  or  brown  and 
something  opaque.  In  the  peritonaeum  it  is  semitransparent,  yel- 
low, or  greenish,  sometimes  with  various  shades  of  red  or  even 
brownish,  like  chocolate  or  coffee.  In  each  of  the  three  last  cases 
it  is  invariably  combined  with  albuminous  matter. 

The  hypothesis  of  Cullen,  who  ascribes  this  inordinate  accumu- 
lation to  any  cause  which  increases  exhalation  or  diminishes  ab- 
sorption, though  plausible,  is  too  general,  and  does  not  comprehend 
all  the  facts  of  the  case.  One  of  the  most  uniform  and  powerful 
agents  in  augmenting  exhalation  from  serous  surfaces  is  that  state 
of  the  capillaries  in  which  they  are  injected,  distended  in  such  a 
manner  as  to  constitute  congestion  or  even  inflammation.  The 
influence  of  this  cause  appears  to  have  been  first  well  understood 
by  Cruikshank,*  Baillie,t  and  Parry ,j:  nor  had  escaped  the  obser- 

* “ The  second  species  of  dropsy  is  very  common,  and  is  that  which  arises  in  conse- 
quence of  previous  inflammation  of  a cavity,  and  may  take  place  in  any  habit  of  body. 
If  an  inflammation  arise  in  a cavity,  it  may  terminate  in  a number  of  different  ways  ; 
one  of  these  is  by  increased  secretion  of  fluid  of  surfaces.  A man  receives  a blow  on 
the  testicle,  inflammation  takes  place,  and  the  consequence  is  frequently  a hydrocele 
or  dropsy  of  the  twiicd  vagiTialis.  A child’s  brain  inflames,  and  this  inflammation 
ends  at  last  in  hydrocephalus^  or  collection  of  water  in  the  brain.  Pleurisy  frequently 
terminates  in  hydrothorax,  or  collection  of  water  in  the  chest.  I have  often  taken 
away  forty  or  sixty  pints  of  w'ater,  w^hich  had  accumulated  in  the  cavity  of  the  abdo- 
men in  the  few  days  the  periton;eal  inflammation  had  lasted,  during  the  usual  species 
of  childbed  fever.  This  is  to  be  considered  as  the  substituting  a less  dangerous  disease 
for  another.  Peritoneal  inflammation  kills  often  in  three  days,  but  acute  may  last 
twenty  years.” — Anatomy  of  the  Absorbing  Vessels. 

Morbid  Anatomy,  p.  57.  4th  edit.  Lond.  1812. 

J Collections  from  the  unpublished  Medical  M ritings,  &c.  p.  205,  207>  20o. 


SEROUS  MEMBRANE. — SERO-ALBUMINOUS  EFFUSIONS.  7ll 


ration  of  Pemberton.  * Its  reality,  however,  was  first  investigated 
and  formally  maintained  by  Grrapengiesser  of  Gottingen, f by  Rush 
of  Philadelphia,:!;  and  was  subsequently  made  the  subject  of  much  re- 
search and  inquiry  by  Wells,  § Blackall,  jj  Crampton,^  and  Ayre. 
The  results  of  the  inquiries  thus  instituted  may  be  stated  in  the  fol- 
lowing manner. 

Though  accumulation  of  fluid  in  the  cavities  of  serous  mem- 
branes depends  on  increased  exhalation  from  the  vessels  of  these 
membranes,  that  exhalation  is  not  to  be  regarded  merely  as  an  in- 
creased form  of  the  natural  action,  but  is  a process  of  morbid  se- 
cretion, depending  on  a state  of  the  blood-vessels,  either  identical 
with,  or  analogous  to  inflammation.  The  vessels  of  the  membranes 
are  numei’ous,  enlarged,  and  in  general  injected.  When  they  are 
not  so,  the  stage  of  injection  has  passed,*  and  been  succeeded  by 
that  of  exhalation.  The  presence  of  albuminous  flakes  in  the  ef- 
fused fluid  furnishes  proofs  of  the  same  description.  The  mem- 
branes are  more  or  less  opaque  and  dull,  and  covered  by  shreds 
and  patches  of  lymph  in  various  spots ; and  fluid  is  effused  into 
the  subserous  tissue.  Thus,  in  several  instances  of  dropsical  infil- 
tration, with  effusion  into  the  cavity  of  the  pleura,  1 have  found 
that  membrane  not  only  vascular,  but  coloured  of  a red-brown  tint, 
opaque,  void  of  its  glistening  aspect,  and  covered  by  patches  of  al- 
buminous exudation.  The  same  is  observed  in  ascites.  One  of 
the  most  decided  examples  is  afforded  by  the  inspection  of  Sir 
James  Craig,  well  described  by  Dr  Somerville.**  The  perito- 
naeum was  found  covered  by  lymph  in  various  points,  and  lymphy 
flakes  were  found  abundantly  in  the  fluid.  On  the  same  point  the 
dissections  of  Dr  Crampton  in  the  Transactions  of  the  Dublin  As- 
sociation afford  unequivocal  and  satisfactory  evidence. 

In  most  cases  of  this  class,  however,  it  will  afterwards  be  shown, 
the  kidneys  are  affected  with  granular  degeneration. 

In  the  case  of  the  cerebral  membranes  it  is  not  quite  so  easy  to 
obtain  evidence.  The  arachnoid  is  averse,  if  I may  use  the  term, 

* Abdominal  Viscera,  p.  12.  “ Sometimes  a resolution  of  the  inflammation  takes 
place  from  the  throwing  out  of  a fluid,  when  ascites  is  produced.” 

t De  Hydrope. 

X Medical  Inquiries  and  Observations.  By  B.  Rush,  M.  D.  Philad.  1805.  Vol.  ii. 
p.  159. 

§ Transactions  of  a Society,  Vol.  iii.  p.  167,  183,  and  194. 

II  Observations  on  the  Natrue  and  Cure  of  Dropsies. 

H Clinical  Report  on  Dropsies.  Transactions  of  Association,  VoL  ii. 

’*  Medico-Chir.  Tr.  Vol.  v.  p.  340,  &c. 


712 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


to  albuminous  exudation  ; and  though  this  occurs  occasionally, 
serous  eflFusion  is  greatly  more  frequent.  The  inflammatory  origin 
of  this  effusion,  however,  is  proved  by  several  circumstances. 

1st,  The  pia  mater  ax\di  choroid  plexus  are  more  or  less,  sometimes 
highly  vascular.  The  arachnoid  is  always  dry,  opaque,  dull,  and 
elevated  by  infiltration  into  the  subjacent  tissue.  In  some  instances 
this  infiltrated  fluid  contains  albuminous  matter  ; and  in  some  patches 
of  lymph  are  deposited  on  the  free  surface  of  the  arachnoid  mem- 
brane. In  one  of  the  most  distinct  cases  of  this  disease  which  fell 
under  my  personal  observation,  I found  the  free  surface  of  the 
cerebral  arachnoid  adhering  to  that  of  the  falciform  process  in  the 
great  fissure  between  the  hemispheres  by  well  marked  filaments  of 
albuminous  exudation. 

2d,  In  the  case  of  violence  inflicted  on  the  head,  which  it  is  well 
known  has  a tendency  to  induce  inflammation,  when  that  inflamma- 
tion proves  fatal,  almost  invariably  we  find  effusion  from  the  mem- 
branes, in  some  cases  to  a great  extent.  In  proof  of  this,  I prefer 
referring  to  the  cases  of  other  observers  than  to  such  as  I have  in- 
spected. In  the  fatal  cases  recorded  by  Pott  and  Dease  the  most 
uniform  appearance  is  water  in  the  ventricles,  which  evidently  pro- 
ceeds from  the  choroid  plexus,  or  inner  division  of  the  cerebral 
membrane.  In  the  numerous  and  well  described  cases  of  Schmucher 
also,  this  eff'usion  is  always  one  of  the  changes  recorded ; and  vascu- 
larity of  the  pia  mater ^ and  dulness  of  the  arachnoid,  with  subarach- 
noid infiltration,  are  frequently  remarked.  Similar  results  may  be 
derived  from  the  cases  given  by  Dr  Thomson,  and  from  those  of 
Dr  Hennen.  In  short,  it  may  be  inferred  that  traumatic  inflam- 
mation of  the  cerebral  membranes  always  Induces  more  or  less 
serous  effusion.  It  is  scarcely  necessary  to  remark,  that  this  explains 
a fact  observed  by  most  practical  physicians,  ♦hat  hydrocephalus  is 
very  often  ascribed  to  blows  or  falls  on  the  head,  the  tendency  of 
which  to  induce  congestion  of  the  vessels  cannot  be  denied. 

3d,  To  the  same  purpose  it  may  be  said,  that  the  effusion  result- 
ing from  the  operation  of  the  process  of  fever,  whether  intermittent, 
remittent,  or  continuous,  demonstrates  the  influence  of  vascular  con- 
gestion in  inducing  it.  Thus  in  ague,  meningeal  effusion  is  not 
uncommon ; in  remittent  it  is  frequent ; and  in  continued  fever  it 
is  perhaps  the  most  usual  cause  of  the  fatal  termination  of  the  disease. 
The  extensive  body  of  evidence  collected  on  this  point  of  late  years 
by  writers  on  remittent  and  yellow  fever,  and  on  the  ordinary  con- 


SEROUS  MEMBRANE CHRONIC  PLEURISY. 


713 


tinued  fever  of  this  country,  renders  it  unnecessary  to  dwell  longer 
on  this  point. 

In  favour  of  the  same  inference,  the  connection  so  often  remark- 
ed between  dropsy  and  hemorrhage  might  be  adduced.  My  limits, 
however,  do  not  permit  me  to  add  more. 


II.  Peculiarities  in  Individual  Inflammations. — The  prin- 
cipal pathological  facts  regarding  the  process  of  inflammation  in 
serous  membrane  have  been  so  fully  stated,  that  it  is  superfluous  to 
dwell  on  the  individual  diseases.  I shall  merely,  after  enumerating 
them,  make  a few  remarks  on  some  peculiarities  presented  by  the 
chronic  forms  of  these  disorders.  They  may  be  arranged  in  the 
following  order,  showing  their  transition  into  dropsies. 


Acute  form. 

Cerebral  envelopes, 

Pleura,  Phimtis, 
Pericardium,  Pericarditis, 
Peritonaeum,  Peritonitis, 
Perididymis,  Orchitis, 


Chronic  form. 
Meningitis  ; Arachnitis, 
Eijipyema, 

Pyocardia, 

Chronic  peritonitis, 
Empyocele, 


Dropsical  form. 

Hydrencephalus. 

Hydrothorax. 

Hydrocardia. 

Ascites. 

Hydrocele. 


Visceral  divisions  of  the  peritonaeum. 


Gastric  peritonasum, 

Gastritis. 

Intestinal  peritona2um, 

Enteritis. 

Colic  peritonaum. 

Colitw. 

Mesenteric  peritonaum, 

Mesenteritis. 

Omentum, 

Epiploitis. 

Cystic  peritonaum. 

Cystitis. 

Hepatic  peritonaum. 

Hepatitis. 

Splenic  peritonaum. 

Lienitis. 

Uterine  peritonaum, 

Hysteritis. 

§ 1.  Chronic  pleurisy  (e/wjot/ema)  is  remarkable  for  the  effects  which 
it  produces.  First,  the  great  accumulation  of  fluid  forces  the  lung 
towards  the  mediastinum  and  spine,  and  compresses  it  into  so  small 
bulk  that  it  appears  to  be  destroyed.  Inspection  shows,  however,  that 
it  is  merely  compressed.  Its  vessels  are  crushed  together ; its  bron- 
chial tubes  and  vesicles  closed ; and  the  whole  organ  is  rendered  un- 
fit for  respiration.  This  is  the  condition  mentioned  by  Broussais  un- 
der the  name  of  atrophied  lung.*  Second,  suppurative  destruction 
may  take  place  in  the  pulmonic  pleura  and  corresponding  part  of  the 
lung,  and  lay  open  one  or  more  bronchial  tubes,  causing  pulmonary 
fistula  pneumothorax.  Sero-purulent  or  purulent  fluid  is  then 
discharged  by  coughing  in  a forcible  and  continuous  stream.  Of 
this  kind  are  many  cases  of  pulmonary  abscess  reported  to  be  cured. 


* Phlegmasies  Chroniques,  Cases  19,  20,  24,  25,  27,  28,  30. 


714 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Thirdly,  suppurative  destruction  may  take  place  in  one  or  more 
points  of  the  costal  pleura,  and  discharge  a considerable  quantity 
of  puriform  fluid  through  openings  between  the  ribs,  which  are  oc- 
casionally carious.*  When  these  two  modes  of  opening  are  com- 
bined, pneumothorax  and  emphysema  take  place.f  Fourthly,  the 
inordinate  accumulation  of  fluid  in  the  left  sac  of  the  pleura  may 
be  so  great  as  to  thrust  the  heart  to  the  sternum,  and  eventually 
into  the  side  of  the  chest,  in  which  its  pulsations  are  then  feltj 
This  change  I have  several  times  witnessed  in  chronic  pleurisy. 

§ 2.  Chronic  peritoneal  inflammation  is  distinguished  by  three  cir- 
cumstances : — Is?,  Purulent  or  sero-purulent  fluid  may  be  secreted 
in  one  or  more  distinct  sacs,  formed  by  the  union,  and  secretion  of 
effused  lymph.  This,  which  was  early  noticed  by  Morgagni,  (Epist, 
xxxiv.  221,)  is  verified  by  J.  Hunter, § and  subsequently  by  Baillie, 
Black, II  Mr  Cooke,  and  others. 

2d,  Purulent  fluid  may  be  secreted  by  the  whole  inflamed  mem- 
brane, without  breach  of  surface.  This  proposition  I should  scarcely 
have  thought  requisite,  after  what  has  been  said  above,  to  state  for- 
mally, did  not  the  valuable  remark  of  John  Hunter,  that  “ the  ca- 
vity of  the  abdomen  acquires  all  the  properties  of  an  abscess,”  ap- 
pear to  he  forgotten  by  Dr  Black  of  Newry,  who,  in  recording  a 
case  in  which  the  ‘‘  abdomen  contained  more  than  two  quarts  of 
thin  purulent  fluid  of  a turbid  appearance,”  seems  to  think  it  extra- 
ordinary that  the  matter  was  secreted  by  inflamed  surfaces.  In 
other  respects  the  case  is  a good  confirmation  of  the  general  prin- 
ciple now  stated.  I may  add,  that  in  several  cases  of  peritonitis 
lasting  for  several  weeks,  which  have  come  under  my  own  observa- 
tion, 1 have  seen  many  folds  of  small  intestine  connected  by  lymphy 
exudation,  and  a considerable  quantity  of  genuine  purulent  fluid 

■*  Miscell.  Curios.  Dec.  iii.  An.  v.  Obs.  49.  Mem.  Med.  Society,  Vol.  iii.  p.  127. 
Kirkland,  Med.  Surgery,  Vol.  ii.  p.  178.  Withering’s  Remarks  on  Dropsy,  &c.  Works, 
Vol.  ii.  p.  304,  § 35. 

+ Treyer,  in  Annals  of  Thomann,  V ol.  i.  Dr  Duncan,  in  Trans.  Med.-Chir.  Society, 
Edin.  Vol.  i.  and  Contributions  to  Morbid  Anatomy,  No.  iv.  Empyema  and  Hydro- 
thorax. in  Med.  Surg.  Journal,  Vol.  xxviii.  p.  302. 

$ Morgagni,  Epist.  xx.  6.  .Barry,  p.  405,  406.  Abercrombie,  in  Med.-Chir.  Trans- 
actions. 

§ “ Inflammation  attacks  the  external  coat  of  an  intestine.  The  first  stage  of  this 
inflammation  produces  adhesions  between  it  and  the  peritonseum  lining  the  abdominal 
muscles.  If  the  inflammation  does  not  stop  at  this  stage,  an  abscess  is  formed  in  the 
middle  of  these  adhesions.” — Treatise  on  the  Blood. 

II  Clinical  .and  Pathological  Reports,  p.  133,  176. 


SEROUS  MEMBRANE. — CHRONIC  PLEURISY. 


715 


bathing  the  adherent  masses,  and  filling  the  hollows  of  the  lumbar, 
iliac,  and  hypogastric  regions.  The  omentum  is  sometimes  glued 
down  at  its  corners  to  a fold  of  ileum ; in  other  instances  it  is  drawn 
up  and  shrivelled  into  a roundish  or  cylindrical  mass. 

^d.  Ulceration  may  take  place  at  one  or  more  points  of  the  mus- 
cular or  intestinal  peritonaeum,  by  a process,  the  mechanism  of  which 
has  been  already  explained.  The  first  is  most  common,  and  may 
be  so  extensive  and  complete  as  to  destroy  the  whole  membrane  on 
the  fore  part  of  the  abdomen,  and  expose  the  transverse  and  straight 
muscles  as  distinctly  as  if  they  were  cleanly  dissected,  and  leave  the 
tendons  of  the  lateral  muscles  in  rags,  partly  gone,  partly  in  the 
form  of  slough.  At  the  same  time,  the  intestines  are  covered  with 
a coat  of  lymph,  which  is  believed  by  Hunter  to  prevent  the  matter 
from  irritating,  and  producing  ulcerative  inflammation  of  the  bow- 
els, and  from  diffusing  itself  over  the  abdominal  cavity.*  Its  chief 
use  is  to  prevent  inflammation  of  the  subserous  tissue. 

The  rarity  of  the  latter,  which  is  well  established,  is  ascribed  by 
Hunter  to  the  indisposition  to  ulceration  manifested  by  the  intestinal 
peritonaeum.f  It  is  the  express  testimony  of  Baillie,  that  he  “ did 
not  recollect  to  have  seen  one  instance  in  which  the  ulcer  had  begun 
on  the  outer  or  peritonseal  surface  of  the  intestines,  and  had  spread 
inwards.”  To  show  that  this  termination,  though  uncommon,  is  not 
unknown,  I mention,  that  of  16  cases  of  chronic  peritonaeal  inflam- 
mation reported  by  Broussais,  in  one  only  did  perforation  of  the  in- 
testines take  place  and  that  in  the  case  of  Willan  above  alluded 
to,  tbe  colon  was  superficially  ulcerated  in  several  places. 

In  the  sero-purulent  and  purulent  collections,  which  are  the  re- 
sult of  peritoneal  inflammation  in  puerperal  females  after  it  has 
passed  the  acute  stage,  a peculiar  mode  of  termination  is  not  un- 
frequently  observed  in  an  opening  taking  place  spontaneously 
generally  at  the  navel,  and  allowing  the  issue  of  a large  quantity  of 
fluid.  This  opening  is  effected  first  by  distension,  the  pressure  of 
the  matter  separating  the  recti,  and  enlarging  the  umbilical  aper- 
ture afterwards  by  laceration,  while  the  peritonaeum  detached  from 
the  supporting  tissues,  and  sustained  only  by  tbe  skin,  at  length 
gives  way,  and  forms  an  opening.  Examples  of  this  are  recorded 

* On  the  Blood,  &c.  Part  ii.  Chap.  vi.  Sect.  vi.  p.  461,  and  Sect.  ix.  p.  467. 
t “ If  the  disposition  for  ulceration  was  equal  on  every  side  of  the  abscess,  it  must 
open  into  the  intestine,  which  is  seldom  the  case,  although  it  sometimes  does.”  P.  236. 
X Phlegmasies  Chroniques,  Section  ii.  Chap.  iv.  Obs.  Iv.  p.  480. 


716 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


by  Hulme,*  Leake, | Denman,:};  Mr  John  Burns, § Gordon,  ||  Arm- 
strong,IT  and  Hey.**  Gordon  and  Denman  mention  cases  in  which 
matter  was  discharged  by  the  urethra  with  favourable  issue.  The 
fluid  of  ascites  in  females  has  a peculiar  exit,  by  which  not  unfre- 
quently  it  escapes,  the  Fallopian  tubes. 

§ 3.  Puerperal  Peritonitis. — That  in  the  disease  termed  puerperal 
fever,  in  a certain  proportion  of  cases,  peritoneal  inflammation  of 
one  or  other  of  the  forms  above-mentioned  takes  place,  is  established 
by  the  observation  of  the  best  authors,  and  by  daily  experience.  In 
every  case  in  which  the  symptoms  of  the  disease  appear  during  life, 
we  find  in  the  peritonaeum  more  or  fewer  of  the  marks  of  the  in- 
flammatory process  above  described.  This  variety  of  peritoneal  in- 
flammation, nevertheless,  is  peculiar  in  commencing  almost  invari- 
ably in  some  part  of  the  peritonaeum  investing  the  organs  of  repro- 
duction. Thus  the  first,  the  most  abundant,  and  the  most  invari- 
able traces  of  inflammatory  action,  are  found  either  in  the  uterine, 
or  the  ovarian  peritonaeum,  or  in  that  of  the  Fallopian  tubes,  espe- 
cially at  their  fimbriated  extremities,  and  within  these  tubes,  or  all 
three  at  once. 

The  most  usual  appearances  which  I have  remarked  in  a large 
proportion  of  cases,  are  opaque,  dull,  and  lustreless  aspect  of  the 
uterine  and  ovarian  peritonaeum  ; blood-spots  or  vascular  injection, 
especially  of  the  ovarian  peritonaeum ; albuminous  exudation  of  the 
uterine  and  ovarian  peritonaeum  often  agglutinating  the  latter  to 
that  of  the  oviferous  tubes ; and  sero-purulent  or  purulent  fluid, 
with  albuminous  shreds,  in  the  hypogastric,  iliac,  and  occasionally 
the  lumbar ybssffi,  and  purulent  or  albuminous  exudation  between 
the  bladder  and  uterus,  and  the  uterus  and  rectum. 

In  a certain  proportion  of  cases,  in  which  the  disease  is  not  at- 
tended by  well-marked  symptoms,  yet  destroys  the  patient  rapidly 
and  certainly,  the  appearances  are  not  very  distinctly  presented. 
The  uterine  peritonaeum  is  covered  with  a sort  of  unctuous  looking 
sero-albuminous  fluid,  or  rather  mere  coating,  which  is  liable  to  be 
entirely  overlooked  by  hasty  observers.  Yet  it  is  seen  all  over  the 
anterior  and  posterior  surface  of  the  womb,  and  along  the  sides  of 
that  organ,  as  a semifluid  glutinous  coating.  In  certain  cases  the 
Fallopian  tubes  and  ovaries  are  covered  by  the  same  coating ; and 

* On  the  Puerperal  Fever.  f O'l  Child-bed  Fever. 

t Introduction,  &c.  Fever.  § Elements,  &c. 

11  Treatise  on  the  Epidemic  Puerperal  Fever,  5th  and  6th  Cases. 

Facts  and  Observations,  p.  158.  **  On  Puerperal  Fever. 


SEROUS  MEMBRANE PUERPERAL  PERITONITIS.  717 


in  one  class  of  cases  the  principal  circumstance  is  purulent  matter 
within  the  Fallopian  tubes. 

The  difficulty  of  recognizing  this  peculiar  unctuous  looking  coat- 
ing has  led  several  persons  to  deny  the  occurrence  of  peritoneal  in- 
flammation in  this  disease.  There  is,  nevertheless,  no  doubt  of  the 
fact,  and  it  should  further  be  remembered  that  this  appearance  takes 
place  in  cases  of  the  greatest  rapidity,  with  the  most  obscure  symp- 
toms, and  in  which  the  disease  is  occasionally  developed  before 
labour.  Some  females  I have  known  die  with  the  disease  unde- 
livered. 

It  must  be  observed,  however,  that  puerperal  fever  is  not  a simple 
but  a complicated  lesion  ; and  that  it  varies  in  diflferent  seasons  in 
the  same  locality,  and  in  different  localities.  Thus  several  forms 
of  the  disease,  to  which  the  name  of  puerperal  fever  is  ap- 
plied, have  been  ascertained  to  affect  the  uterine,  ovarian,  and  ab- 
dominal peritoncRum,  the  womb,  the  ovaries,  and  Fallopian  tubes, 
the  uterine  veins,  the  uterine  lymphatics,  and  the  substance  of  the 
womb  itself.  These  different  elementary  tissues  it  may  affect  either 
separately  or  conjointly ; either  two  or  more  of  them  simultane- 
ously or  successively. 

Of  these  lesions  some  degree  or  form  of  inflammation  of  the  pe- 
ritonaeum is  tlie  most  frequent.  Among  222  cases  inspected  by 
M.  Tonnelle,  in  193  traces  of  peritoneal  inflammation  were  observ- 
ed, consisting  in  more  or  less  redness  of  the  intestinal  or  the  ute- 
rine penYoKaeww?,  or  of  the  mesentery  or  omentum,  sometimes  with 
thin  albuminous  exudation,  sometimes  with  copious  exudation  of 
opaque  sero- albuminous  fluid. 

In  puerperal  females  peritonitis  appears  to  originate  most  com- 
monly either  in  the  uterine  peritonceum^  or  in  that  of  the  ovaries,  or 
in  that  of  the  Fallopian  tubes,  or  in  the  mucous  or  inner  lining  of 
these  tubes.  It  is  not  easy  to  say  to  which  of  these  points  it  shows 
the  preference.  If  we  trust  to  the  numerical  results  given  by  M. 
Tonnelle,  the  disease  commences  most  commonly  in  some  point  of 
the  uterine  peritonaeum^  and  next  to  that  in  the  ovarian  peritonaeum. 

This  observer  foimd  among  222  inspections  of  the  bodies  of  fe- 
males, destroyed  by  symptoms  of  puerperal  fever,  the  following 
proportions  of  the  lesions  now  referred  to, — 

Cases. 

Marks  of  peritoneal  inflammation  in  . 193 

Changes  in  the  womb  and  its  appendages  in  . 197 

Difference  in  favour  of  affections  of  womb,  . 4 


718 


GENERAL  ANI)  PATHOLOGICAL  ANA  TOMY. 


Cases. 

Marks  of  inflammation  of  the  peritonaeum  and  changes  in  the  womb 
or  its  appendages  were  variously  associated  in  . 165 

separated  in 

Viz.  traces  of  peritonitis  without  affection  of  womb  in  28 
changes  in  womb,  including  those  of  ovaries  and  veins, 
without  affection  of  peritonreum,  in  . 29 

In  a considerable  number  of  cases  of  this  disease  which  I had  oc- 
casion to  inspect,  the  peritoneal  covering  of  each  ovary  was  enclosed 
in  a layer  of  albuminous  exudation.  In  this  the  fimbriated  extre- 
mities of  the  oviferous  tubes  were  imbedded  ; and  in  that  of  one 
side  in  several  cases  the  adhesion  was  tolerably  firm.  The  usual 
blood-spots  indicating  organization  were  distinct.  Between  the 
uterus  and  rectum  in  several  cases  was  an  extensive  albuminous  exu- 
dation, forming  a cyst  containing  purulent  fluid ; and  a smaller  one 
of  the  same  kind  was  found  between  the  uterine  and  vesical  perito- 
naeum. In  more  severe  cases  the  inflammatory  process  spreads  over 
the  intestinal  peritonaeum,  and  produces  its  usual  effects. 

The  commencement  of  this  disease  in  the  uterine  and  ovarian 
peritonaeum  is  not  wonderful,  when  the  extraordinary  distension  of 
that  membrane  during  the  latter  months  of  pregnancy  is  consider- 
ed. Denman-  remarks  that  there  are  not  wanting  instances  in  which 
it  has  been  evidently  forming  before  delivery,  or  during  labour ; 
Joseph  Clarke  states  that  he  saw  reason  to  date  the  commencement 
of  several  cases  from  before  delivery,  and  refers  to  two  in  which 
this  conclusion  was  justified  by  the  speedy  extinction  of  life  after 
labour,  and  the  appearances  on  inspection,  (44) ; and  Hey  refers 
to  two  cases,  one  fatal,  in  which  symptoms  appeared  previous  to  de- 
livery. These  inferences  I have  now  had  occasion  to  verify  more 
than  once.  I had  occasion  in  the  summer  of  1828  to  detract  in 
two  days  fifty  ounces  of  blood  with  corresponding  antiphlogistic 
measures,  in  order  to  check  incipient  symptoms  of  peritoneal  in- 
flammation in  a lady  during  the  latter  part  of  pregnancy. 

Though  peritoneal  inflammation  in  puerperal  females,  compli- 
cated as  it  often  is  with  inflammation  of  the  ovaries,  of  the  uterine 
veins,  or  of  the  uterine  lymphatics,  often  terminates  fatally,  and 
that  at  an  early  period ; yet  in  certain  cases  it  does  not  immedi- 
ately end  in  this  way,  but  causes  so  much  destruction  of  parts,  or 
gives  rise  to  such  morbid  products,  that  the  patient,  after  lingering 
for  four  or  six  weeks  in  a state  of  great  feebleness,  usually  with 
hectic  fever,  is  suddenly  or  slowly  cut  ofli'. 

4 


SEROUS  MEMBRANE. PUERPERAL  PERITONITIS.  719 

The  morbid  products  and  changes  which  take  place  under  these 
circumstances,  prove  at  once  the  destructive  effects  of  the  disease, 
and  the  great  eflPorts  made  by  the  system  to  counteract  them. 

Thus  in  one  instance,  in  which  the  disease  had  been  proceeding 
for  three  weeks,  the  patient  was  brought  to  the  hospital  with  the 
symptoms  still  present,  though  in  a milder  form.  Pain  was  much 
abated  though  not  gone ; swelling  and  tension  were  likewise  di- 
minished. But  habitual  fever  w^as  present ; and  in  the  hypogastric 
region,  on  the  left  side  of  the  pubes,  was  a swelling,  painful,  elastic, 
pointing,  soft,  and  evidently  containing  some  fluid.  In  the  course 
of  a few  days,  a spontaneous  opening  took  place,  and  much  puru- 
lent matter  was  discharged,  apparently  with  relief  to  the  symptoms. 
The  discharge  continued,  however,  and  the  hectic  symptoms  and 
wasting  did  not  subside.  Notwithstanding  all  means  calculated  to 
abate  the  discharge  and  promote  adhesion,  the  former  continued, 
and  in  the  course  of  about  four  weeks  more  the  patient  expired. 

It  was  then  found  that  around  the  left  ovary  and  Fallopian  tube 
had  been  deposited  a great  quantity  of  lymph  which  connected 
these  parts  to  the  muscular  peritonaeum  of  the  left  pubo-inguinal 
region,  and  formed  connections  also  with  the  fundus  uteri ; that 
within  this  mass  of  lymph  had  been  contained  a quantity  of  puru- 
lent matter  ; that  the  abscess  which  was  found  in  the  left  pubic  re- 
gion at  admission  had  communicated  with  this  purulent  cyst ; that 
the  ulcerated  opening  which  had  been  formed  through  this  abscess  in 
the  left  pubal  region  still  communicated  with  the  interior  of  this 
cyst ; and  that  the  latter  extended  downwards  a little  on  the  left 
angle  and  side  of  the  uterus.  The  left  ovary  was  enlarged,  and 
contained  various  purulent  collections  of  small  size.  The  left  Fal- 
lopian tube  contained  purulent  matter.  Lymph  and  purulent 
matter  were  deposited,  though  less  abundantly,  in  the  fundus 
uteri,  in  the  angle  between  the  uterus  and  rectum,  in  that  between 
the  uterus  and  bladder,  and  on  the  right  side  of  the  uterus. 

In  a similar  case  which  occurred  to  Dr  Lee  the  ovary  was  con- 
verted into  a large  purulent  cyst,  which  had,  by  coagulable  lymph, 
formed  adhesions  with  the  abdominal  parietes,  and  discharged  its 
contents  through  an  ulcerated  opening. 

This  mode  of  involving  the  ovaries  and  Fallopian  tubes  in  lymph 
containing  purulent  matter  and  then  forming  adhesions  with  other 
contiguous  parts,  as  the  muscular  or  the  pelvic  peritonaeum,  or 
the  rectum,  is  by  no  means  uncommon  in  that  class  of  cases  in 


720 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


which  lymph  is  effused,  and  the  tendency  to  limit  inflammation  is 
strong.  This  tendency  to  limitation,  in  short,  by  effusion  of  coa- 
gulahle  lymph,  is  either  connected  w'ith  the  more  favourable  and 
less  violent  form  of  the  disease,  or  it  is  an  indication  that  the  dis- 
ease is  not  so  speedily  and  certainly  fatal. 

One  of  the  most  extraordinary  terminations  of  cases  of  this  kind 
occurred  in  a patient  under  my  own  care,  in  the  Royal  Infirmary 
of  this  place.  A woman  had  been  previously  treated  for  fever 
supposed  to  be  typhoid,  until  the  symptoms  had  proceeded  so  far 
as  to  render  the  effect  of  active  treatment  questionable.  Blood, 
however,  was  drawn  from  the  arm,  and  afterwards,  by  means  of  the 
repeated  application  of  leeches,  from  the  right  inguinal  region, 
where  pain  was  felt,  and  dulness  was  recognized.  About  the  fourth 
week  after  she  came  under  my  care,  a quantity  of  purulent  matter 
was  discharged  from  the  rectum,  with  some  transitory  relief  to  the 
symptoms.  Death,  however,  took  place ; and  on  dissection  I found 
on  the  right  side  of  the  rectum,  between  that  bowel  and  the  uterus, 
an  ulcerated  opening  from  the  cavity  of  the  peritonaeum,  whence 
the  matter  had  escaped.  The  right  ovary  was  found  covered  with 
purulent  lymph  ; and  the  right  Fallopian  tube  was  filled  with  thick 
purulent  matter. 

§ 4.  Tabes  mesenterica;  Marasmus. — A species  oichromc peritonitis^ 
giving  rise  in  children  to  the  symptoms  of  this  disease,  is  described 
by  Dr  George  Gregory.  Its  anatomical  characters  are  much  the 
same  as  in  the  ordinary  instances  of  peritoneal  inflammation  ; but 
it  also  tends  to  induce  thickening  of  the  peritonaeum,  secretion  of 
matter  termed  scrofulous,  {tubercular  ? tyromaious  9)  and  finally 
ulceration  of  the  peritonaeum.  In  consequence  of  this  ulceration, 
the  mucous  and  peritoneal  surfaces  of  the  bowel  communicate  di- 
rectly, so  that  instead  of  forming  a continuous  canal,  as  in  the 
normal  condition,,  they  constitute  a mass  of  tubes  communicating 
freely  with  each  other,  and  with  thickened  and  ulcerated  perito- 
naeum, by  numerous  openings.  From  the  early  symptoms  com- 
bined with  these  changes.  Dr  Gregory  considers  this  disorder  as 
primarily  commencing  in  the  peritonaeum.*  The  justice  of  this 
view  I have  already  attempted  to  consider.f  I have  only  to  observe, 
that  not  only  the  symptoms,  but  even  the  appearances  of  peritoneal 
inflammation  may  he  explained,  by  supposing  the  ulcerative  pro- 
cess to  originate  in  the  mucous  membrane,  and  proceed  to  the  pe- 

* Observations  on  the  scrofulous  inflammation  of  the  Peritonaeum,  &c.  Med.-Chir. 
Transact.  Vol.  xi.  p.  258.' 

•f  See  page  650,  § 13. 


CEREBRAL  SEROUS  MEMBRANE MENINGITIS. 


721 


ritoneal,  in  which  the  effusion  of  the  contents  of  the  tube  neces- 
sarily produce  inflammatory  exudation.  For  a case  illustrating 
this  mode  of  progress,  I refer  to  Howship,  p.  264. 

§ 5.  Meningitis  and  Arachnitis. — These  two  affections  are  gene- 
rally combined, — in  other  words,  inflammation  of  the  pia  mater  is 
generally  accompanied  with  that  of  the  arachnoid  membrane.  It 
assumes  acute,  subacute,  and  chronic  forms. 

The  acute  and  subacute  forms  constitute  the  disease  described 
by  practical  authors  under  the  name  of  water  of  the  head,  loater  of 
the  brain,  hydrocephalus,  and  hydrencephalus.  This  inference, 
which  was  originally  advanced  by  Quin,  and  adopted  by  Rush  and 
Garnet,  was  first  verified  by  Cheyne,  and  has  been  since  amply  con- 
firmed by  the  inspections  of  Golis,  the  inquiries  of  Dr  Blackall,  of 
Dr  Ayre,  Dr  Abercrombie,  the  dissections  and  researches  of  Pa- 
rent-Duchatelet,  Martinet,  and  Senff.  The  proofs  collected  by 
these  authors,  it  is  unnecessary,  after  the  general  remarks  already 
submitted,  to  detail.  From  the  account  also  of  the  distribution  of 
the  proper  cerebral  membrane,  it  is  easy  to  explain  the  necroscopic 
phenomena  of  hydrocephalic  brains.  The  natural  result  of  this 
distribution  is,  that  when  the  membrane  is  inflamed,  and  its  vessels 
in  consequence  secrete  watery  fluid,  while  that  from  the  outer  divi- 
sion is  deposited  beneath  the  arachnoid  coat,  that  of  the  inner  trickles 
from  the  membrane,  on  the  figurate  surface  of  the  brain,  or  in  the 
ventricles,  in  which  its  effects  are  in  proportion  to  its  quantity.  If 
small,  it  produces  little  change  on  the  parts  of  the  brain.  If  co- 
pious, it  raises  the  vault,  pushes  out  the  walls  of  the  ventricles,  en- 
larges their  capacity  and  dimensions,  breaks  down  the  median  sep- 
tum, forming  a large  communicating  aperture,  and  may  ultimately 
extrude  the  substance  of  the  organ,  and  render  it  so  thin  as  to  give 
it  the  appearance  of  a mere  bag,  containing  a considerable  quantity 
of  water. 

In  some  instances  fluid  is  not  found  in  the  ventricles.  The  pia 
mater  and  plexus,  however,  are  highly  injected ; the  arachnoid  is 
opaque,  dull,  and  dry-looking  ; and  the  subarachnoid  tissue  is  in- 
filtrated. This  demonstrates  that  the  symptoms  of  the  disease  de- 
pend not  on  the  effusion,  but  on  the  previous  vascular  injection. 

In  addition  to  these  proofs  derived  from  inspection,  that  the  fluid 
proceeds  not  from  the  brain  but  its  membranes,  it  may  be  added, 
that  in  the  foetal  state,  previous  to  the  formation  of  brain,  fluid  may 
be  derived  from  the  congested  vascular  membrane.  The  new  ac- 

z z 


722  GENERAL  AND  PATHOLOGICAL  ANATOMY. 

tion  thus  established  gives  a sudden  check  to  the  normal  action  of 
the  vessels ; and  as  the  formation  of  the  brain  is  thus  interrupted, 
the  individual  is  born  aneneephalous.  The  same  process  taking 
place  in  the  vertebral  portion  of  the  membrane  during  the  early 
months  of  foetal  life,  causing  at  once  serous  effusion,  interruption 
to  the  growth  of  the  chord,  and  arresting  that  of  the  spinal  plates, 
and  their  mutual  union,  constitutes  s-pina  bifida. 

The  influence  of  acute  meningitis  in  deranging  the  mental  facul- 
ties, though  questioned  by  Bayle,  appears  to  me  undoubted,  for  the 
following  reasons. 

Is#,  In  several  cases  of  the  disease  taking  place  in  adults,  and  in 
which  its  nature  was  confirmed  by  accurate  inspection,  I have  re- 
marked the  same  confusion  of  thought,  incapacity  of  judgment,  and 
incoherence  of  speech  as  in  the  maniacal.  In  general,  in  this  de- 
lirium gay  and  pleasurable  ideas  predominate.  In  the  most  dis- 
tinct of  these  cases,  to  which  I have  already  alluded,  the  nature  of 
the  disease  was  unequivocally  demonstrated,  not  only  by  the  fluid 
of  the  ventricles,  but  by  the  vascularity  of  the  pia  muter  and  plexus, 
subarachnoid  infiltration,  dulnessof  the  arachnoid,  and  albuminous 
exudation  from  the  free  surface  of  that  membrane.  2t/,  In  seve- 
ral cases  of  the  disease  occurring  in  infants,  without  proving  im- 
mediately fatal,  I have  traced  to  this  cause  a degree  of  idiocy  which 
was  supposed  to  be  congenital.  This  idiocy  is  in  many  cases  asso- 
ciated with  deafness,  dumbness,  or  both,  sometimes  with  squinting, 
and  sometimes  with  amaurotic  blindness.  Upon  inquiry,  it  always 
appeared  that  the  infant  had  undergone  soon  after  birth  an  anoma- 
lous and  little  understood  disorder,  after  which,  hearing  and  sight 
seemed  much  impaired,  and  the  vivacity  of  the  infantile  age  was 
not  observed.  Inspection  at  a subsequent  period  demonstrated  the 
nature  of  the  affection. 

Symptomatic  meningeal  inflammation,  or  rather  congestion,  I 
have  formerly  said,  takes  place  in  fever  continued,  intermittent, 
and  remittent,  after  injuries  of  the  head,  and  occasionally  in  other 
diseases. 

From  the  appearances  of  a considerable  number  of  cases  of  the 
ordinary  continued  fever  of  this  country,  which  since  the  beginning 
of  1817  I have  inspected  personally,  or  have  seen  inspected,  I in- 
fer that  suhacute  congestion  of  the  cerebral  membranes  is  one  of 
the  most  frequent  phenomena  of  that  disease,  and  one  which  very 
often  contributes  to  its  fatal  termination.  I have  elsewhere  at- 
tempted to  show,  however,  that  this  is  not  the  cause  of  fever ; and 

4 


CEREBKAL  SEROUS  JIEMBRANE — :PHTHISICAL  DELIRIUM.  723 


though  the  cause  of  many  of  its  symptoms,  especially  the  confused 
thought  and  incoherent  speech,  that  it  is  one  only  of  an  extensive 
and  general  morbid  state  of  the  capillary  system  induced  by  the 
action  of  fever.  It  may  nevertheless  occasionally  amount  to  in- 
flammation. 

With  the  admission  of  the  facts  now  stated,  further,  it  must  be 
remembered,  that  the  main  cause  of  the  symptoms  of  headach,  de- 
lirium, convulsions,  and  stupor  during  life,  and  of  the  appearances 
after  death,  is  the  circulation  in  the  vessels  of  the  brain  of  blood 
not  oxygenated,  blood  containing  much  carbonaceous  matter,  and 
several  elements  which  in  the  state  of  health  are  expelled ; blood, 
in  short,  poisoned  by  the  operation  of  fever,  of  whatever  type. 

§ 6.  Delirium  in  the  Phthisical  not  an  instance  of  Metastasis. — 
Subacute  meningeal  inflammation  I have  seen  take  place  in  the  phthi- 
sical during  the  last  days  or  weeks  of  existence.  Upon  examining 
the  brains  of  persons  of  this  description  who  have  had  delirium  for 
some  time  before  death,  the  pia  mater  and  choroid  plexus  are  more 
or  less  sometimes  highly  injected ; the  arachnoid  is  dull,  opaque, 
and  lustreless ; the  subarachnoid  tissue  is  infiltrated,  especially  in 
the  vicinity  of  the  vessels ; and  serum  is  effused  in  the  ventricles. 
In  an  extreme  case  of  this  nature,  which  occurred  under  the  care 
of  Dr  Renton,  and  in  which  the  patient  had  cfcZzVfwwz  amounting  to 
mania  for  three  weeks  previous  to  death,  I found  among  other  le- 
sions, the  whole  pia  mater  most  extensively  injected,  and  its  minute 
vessels  of  a scarlet-red  colour,  while  the  large  vessels  were  filled 
with  dark  blood.  The  scarlet-coloured  capillaries  were  distinct 
and  abundant  at  the  convoluted  surface,  and  in  particular  at  the 
base  of  the  brain,  and  in  the  portion  which  covers  the  outer  surface 
of  the  hippocampus  major.  The  arachnoid  was  dull,  opaque,  and 
elevated  by  subserous  infiltration.  At  the  inner  margins  of  the 
hemisphere,  in  the  neighbom’hood  of  the  falx,  the  arachnoid  of  the 
pia  mater  adhered  to  that  of  the  dura  mater  with  albuminous  effu- 
sion ; and  pisiform  or  lenticular  eminences  like  those  described  by 
Greding  and  others  were  found  proceeding  from  the  pia  mater. 
The  choroid  plexus  was  also  injected ; and  serum  to  the  amount 
of  about  one  ounce  or  ten  drachms  was  found  ‘in  the  ventricles. 
The  substance  of  the  convoluted  or  gray  matter  of  the  brain  was 
extensively  traversed  by  reddish  vessels,  in  which  the  blood  was 
still  fluid. 

§ 7.  Inflammation  of  the  Choroid  Plexus  or  central  Pia  Mater. 
— This  lesion,  though  rai’e,  is  observed  occasionally  to  take  place. 


724 


GENERAL  AND  PATHOLOGICAL  ANATOM T. 


The  choroid  plexus  becomes  thick,  solid,  and  firm,  and  is  matted 
into  a mass  with  lymph  effused  between  its  folds  and  interstices. 
It  may  then  be  drawn  from  the  ventricles  and  their  divisions  like 
a thick  solid  mass.  The  ventricles,  at  the  same  time,  contain  tur- 
bid sero-purulent  fluid. 

This  change  commmonly  affects  both  choroid  plexuses,  in  all 
their  divisions. 

The  external  effects  by  which  it  is  attended  are  variable  and  not 
very  distinctive.  The  patient,  besides  shivering  and  being  hot  and 
uncomfortable,  is  feeble,  tremulous,  and  has  a sort  of  paraplegic 
appearance  in  the  lower  extremities,  and  sometimes  of  the  whole 
person.  The  patient  has  a stupid  look,  complains  little,  except  of 
weight  of  the  head,  and  weakness  of  vision  or  blindness.  In  some 
instances  he  is  at  first  affected  by  ringing  in  the  ears,  and  is  after- 
wards deaf.  At  length  speech  is  imperfect ; great  weakness  follows, 
generally  with  coma ; and  after  some  hours  of  this,  death  ensues. 

§ 8.  Chronic  Meningeal  Inflammation.  The  pathological  causes  of 
insanity. — However  general  be  the  opinion,  that  mental  derange- 
ment may  exist  independent  of  anatomical  change  in  the  state  of 
the  brain  or  its  coverings,  we  find  in  the  writings  of  various  au- 
thors, and  in  the  results  of  anatomical  inspection,  ample  proof  of 
four  facts  ; that,  though  mental  derangement  m'ay,  in  first  attacks 
and  in  cases  of  short  duration,  depend  on  some  dynamical  change 
in  the  circulation  of  the  brain  or  its  membranes,  yet  when  long 
continued,  it  is  always  connected  with  some  change  in  the  organi- 
zation of  these  parts ; that  mental  derangement,  as  commonly 
observed,  is  usually  connected  with  a morbid  state  of  the  mem- 
branes, or  the  brain,  or  both ; that  most  abnormal  changes  give 
rise,  sooner  or  later,  to  confusion  of  thought,  incoherent  ideas,  and 
insane  actions ; and  that  deranged  intellect  is  one  only  of  several 
symptoms  which  may  occur  in  consequence.  Already,  when  enu- 
merating^ the  morbid  changes  incident  to  the  brain,  I have  alluded 
occasionally  to  several  of  those  which  may  induce  insanity.  I am 
now  to  advert  to  states  of  the  cerebral  membranes,  which,  there  is 
every  reason  to  believe,  are  a very  uniform  cause  of  that  malady. 

The  elaborate  inspections  of  Greding,  to  whom  I have  had  occa- 
sion formerly  to  allude,  afford  the  first  traces  of  comprehensive 
views  on  the  abnormal  states  of  the  brain  and  its  coverings,  in  the 
persons  of  the  maniacal  and  epileptico-maniacal  insane.  Accord- 
ing to  the  researches  of  this  physician,  the  pia  mater  and  arachnoid 
membrane  are  rarely  sound  in  those  affected  with  insanity.  In 


CEREBRAL  SEROUS  MEMBRANE — INSANITY. 


725 


120  cases  inspected,  though  in  a few  (5)  the  pia  mater  is  stated  to 
be  pale,  in  more  (9)  it  was  reddish  ; and  in  a number  still  greater 
its  vessels  were  injected  with  dark  blood.  The  exterior  surface 
was  in  29  cases  white,  thick,  and  mucous ; sometimes  dry  and  lar* 
daceous,  like  the  buffy  coat  of  inflamed  blood,  near  the  vertex,  along 
the  mesial  margins  of  the  hemispheres.  In  29  cases  this  alteration 
extended  more  generally  over  the  membrane.  In  9 it  was  observed 
over  the  convex  and  plane  surfaces  of  the  hemispheres ; and  in  6 
it  extended  round  the  cerebellum  and  medulla  oblongata.  The 
white,  thick,  opaque  appearance  Greding  ascribes  to  subarach- 
noid effusion ; the  dry  lardaceous  to  albuminous  exudation.  In 
37  cases  he  found  minute,  pisiform,  or  lenticular  eminences,  like  a 
mustard-seed,  a hemp-seed,  or  a pea,  soft  or  hard,  disseminated 
over  the  membrane ; in  27  cases  more  copious  and  thickly  set ; and 
in  14  cases  accumulated  abundantly.  These  bodies,  which  are  to 
be  distinguished  from  the  glandules  of  Pacchioni,  by  situation,  soft 
consistence,  and  milky  colour,  appear  to  be  a product  of  the  in- 
flammatory process.  I have  occasionally  seen  them  in  subjects  in 
whom  the  traces  of  chronic  inflammation  were  distinct.* 

Similar  changes  in  the  cerebral  membranes  were  recognised  by 
Joseph  Wenzel  of  Mayence,f  an  1 Chiarugi  of  Florence.  The 
latter  especially,  among  59  necroscopic  inspections  of  insane  per- 
sons, found  in  54  more  or  less  thickening  of  the  membranes,  serous 
infiltration  of  the  subarachnoid  tissue,  with  or  without  injection  of 
the  capillaries,  and  serous  flui  i to  greater  or  less  amount  within 
the  ventricles. J 

Much  the  same  results  may  be  derived  from  <‘he  necroscopic  re- 
ports of  Haslam  and  Marshall.  Of  37  cases  of  insane  persons  ex- 
amined by  the  former,  whatever  was  the  state  of  the  brain,  the 
membranes  were  unsound  in  all  except  one  (the  33d);  and  in  this 
“ considerable  determination  of  blood  to  the  brain  shows  that  the 
capillaries  of  the  pia  mater  were  inordinately  loaded.  In  23  of 
these  cases,  the  pia  mater  was  injected  and  loaded  with  blood,  more 
or  less  reddened  or  disordered  in  its  capillary  system.  In  24  cases, 
the  arachnoid  membrane  was  opaque ; in  some  instances  of  milky 

* MelanchoHco-Maniacorum  et  Epilepticorum  quomndam  in  Ptochotropheo  Wald- 
heimensi  demortuorum  sectiones  tradit  J.  E.  Greding,  Continuatio  2da.  Apud  Ludwig 
Adversaria,  VoL  ii.  Part  iii.  p.  449. 

t Observations  sur  le  Cervelet  et  sur  les  diverses  parties  du  cerveau  dans  les  Epilep- 
tiques,  par  Jos.  Wenzel,  D.  M.  &c.  Traduit  par  M.  Breton.  Paris,  1811. 

t Della  Pazzia  in  genere  e in  specie,  Trattato  Medico- Analitico  con  una  centuria 
d’Osservazioni.  3 Tomi,  8vo.  Firenze,  1793,  1794. 


726 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


opacity ; in  several  thickened ; and  in  one-half  at  least  with  infil- 
tration into  the  subarachnoid  tissue.  Of  these  24,  13  belong  to 
the  first  class  in  presenting  traces  of  injection  of  the  pia  mater.  In 
21  cases,  serous  fluid  varying  in  amount  from  two  tea-spoonful  to 
four,  six,  or  eight  ounces  was  found  in  the  ventricles ; and  of  these 
also  10  corresponded  with  the  first  class  in  presenting  traces  of  me- 
ningeal inflammation  more  or  less  intense.  The  presence  of  this 
fluid  in  the  cerebral  cavities,  I have  already  shown,  indicates  pre- 
vious vascular  congestion  of  the  choroid  plexus  ; and  though  this 
membrane  was  not  in  all  instances  much  or  evidently  affected,  yet, 
since  in  several  it  was  vascular,  thickened,  vesicular,  or  indurated, 
the  appearance  of  fluid  in  the  cavities  is  as  unequivocal  a mark  of 
previous  inflammation  as  if  it  had  been  reddened,  injected,  or  pe- 
netrated by  extravasated  blood.  The  opacity,  both  macular  and 
diffuse.  Dr  Haslam  regards  as  marks  of  inflammation  ; and  the  sub- 
arachnoid infiltration  is  of  the  same  nature.  In  several  cases,  (5, 
7,  8,  14,  15,  18,)  the  injection  had  proceeded  to  extravasated  patches. 
In  one  case,  in  which  the  patient  died  hemiplegic,  the  right  lateral 
ventricle  was  distended  with  dark-coloured  blood  which  had  issued 
from  the  choroid  plexus ; and  in  one,  in  which  the  patient  dropped 
dowm  lifeless  in  a moment,  much  blood  was  extravasated  between 
the  cerebral  membranes.* 

The  cases  dissected  by  Dr  Marshall  about  the  same  time,  but 
published  some  years  after,  furnish  similar  results.  Of  22  cases  of 
insane  persons  w hose  brains  were  inspected  by  this  anatomist,  in  21 
serous  fluid,  varying  in  amount  from  1,  2,  or  4,  to  12  ounces,  was 
found  in  the  cerebral  cavities;  and  in  17  of  these  21  cases  similar 
effusion  was  found  in  the  subarachnoid  tissue  occasionally  to  the 
extent  of  elevating  the  arachnoid  membrane  in  minute  vesicles  or 
cysts,  (cases  6,  8,  9,  18,  22.)  Though  the  pia  mater  is  said  to  have 
been  injected  in  four  cases  only,  and  the  arachnoid  to  have  been 
opaque  in  two,  it  results  from  the  fluid  effused  into  the  ventricles 
or  between  the  membranes,  from  the  vascularity  of  the  substance 
of  the  brain,  and  from  the  facility  with  which  the  pia  mater  was  de- 
tached from  the  convoluted  surface,  that  the  capillaries  of  the  lat- 
ter membrane  were  in  a morbid  state.f  It  is  further  to  be  remark- 
ed, that  in  nine  of  these  cases  were  the  arteries  of  the  brain  opaque, 

* Observations  on  Madness  and  Melancholy,  &c.  by  John  Haslam,  2d  edition. 
London,  1809. 

T The  Morbid  Anatomy  of  the  Brain  in  Mania  and  Hydrophobia,  &c.  &c.  collected 
from  the  Papers  of  the  late  Andrew  Marshall,  M.  D.  1815. 


CEREBRAL  SEROUS  MEMBRANE INSANITY. 


727 


thickened,  steatomatous,  or  ossified, — a condition  highly  favourable 
for  deranging  the  capillary  circulation  of  the  membranes  or  the  in- 
closed organ. 

These  results  are  important  in  enumerating  the  most  uniform 
morbid  appearances  found  in  the  cerebral  membranes  of  the  mani- 
acal. Their  chief  value,  however,  consists  in  the  verification  which 
they  have  since  received  from  the  researches  of  Neumann  of  Ber- 
lin, and  Bayle  and  Calmeil  of  Paris.  From  the  inquiries  of  the 
second  of  these  authors  especially,  it  appears  almost  established  that 
a state  of  chronic  inflammation  of  the  cerebral  membranes  is  inva- 
riably the  cause  of  insanity.  My  limits  do  not  permit  me  to  detail 
the  whole  of  the  proofs  on  which  this  inference  is  founded ; nor  is 
it  necessary,  after  collating  the  dissections  of  Greding,  Chiarugi, 
Haslam,  and  Marshall.  A short  statement  of  the  principal  mor- 
bid changes  recognized  by  M.  Bayle  will  be  sufficient  to  show  how 
far  the  inference  is  justified  by  facts. 

Is^,  The  most  constant  anatomical  character  of  this  state  of  the 
cerebral  membranes  is  injection,  more  or  less  intense  and  extensive, 
of  the  cellular  vascular  web  of  the  pia  mater.  The  vessels  are 
loaded ; the  membrane  is  red  or  scarlet ; and  blood  trickles  from 
all  parts  on  removing  it  from  the  brain.  In  other  instances,  its  in- 
terstices are  distended  with  serous  fluid,  which  gives  it  a pale  gray 
colour,  and  increases  its  volume  and  thickness.  The  arachnoid  is 
reddish  scarcely  once  in  16  or  20  cases. 

2J,  The  arachnoid  becomes  opaque  and  thickened,  especially  in 
the  convex  centre  of  the  hemispheres,  at  their  mesial  margin,  and 
on  their  mutual  surface.  This  thickness,  which  may  be  so  great  as 
to  approach  that  of  the  pleura,  the  pericardium,  the  dura  mater,  or 
macerated  parchment,  M.  Bayle  ascribes  not  to  albuminous  deposi- 
tion on  its  surface,  but  to  development  of  vessels,  and  extravasation 
of  matter  in  its  substance. 

Zd,  The  meningeal  injection  very  generally  terminates  in  serous 
effusion,  either  from  the  free  surface  of  the  arachnoid  membrane  in- 
to the  subarachnoid  tissue,  or  from  the  arachnoid  of  the  choroid 
plexus,  constituting  eflfusion  into  the  ventricles. 

^th.  Albuminous  exudation  occurred  in  ^th  of  the  subjects  at  the 
free  surface  of  the  arachnoid  of  the  dura  mater,  covering  its  whole 
extent,  confined  to  the  convexity  of  one  or  both  hemispheres,  to  the 
falx,  or  to  the  occipital  region, — applied,  but  not  adhering  to  the 
cerebral  arachnoid. 


728 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


5th,  Adhesions  of  the  two  surfaces  of  the  arachnoid  occurred  no 
more  than  8 or  10  times  in  100  instances.  They  are  most  com- 
mon in  the  great  fissure,  and  once  or  twice  were  observed  in  the 
ventricles.  In  one  case,  in  which  the  disease  was  complicated,  M. 
Bayle  found  the  two  folds  of  the  arachnoid  intimately  united  by' the 
interposition  of  an  albuminous  patch. 

Qth,  The  membranes  adhered  to  the  convoluted  surface  with  un- 
usual firmness,  so  as  to  carry  away  portions  of  brain  in  one-half 
of  the  cases.  This  took  place  in  spaces  varying  in  size  from  a 
lentile  or  a beau  to  a five-franc  piece  or  move.  The  connection  of 
this  change  with  inflammation  is  denoted  by  the  vascularity  and 
abnormal  thickness  of  the  membranes  at  the  adhering  points. 

Itk,  The  pisiform  granulations  of  Greding  were  found  in  not 
more  than  of  the  subjects;  a degree  of  rarity  probably  depen- 
dent on  the  circumstance  that  they  are  in  general  a product  of 
long-continued  inflammation. 

Sth,  Bloody  extravasation  in  the  arachnoid  cavity,  which  belongs 
to  a subsequent  head,  was  found  in  about  |-th  of  the  cases. 

From  these  and  similar  facts,  and  from  the  cases  of  M.  Calmeil, 
it  results  that  the  cerebral  membranes,  more  especially  the  tomen- 
tose  and  vascular  surface  of  the  proper  membrane,  {pia  mater  and 
choroid  plexus,)  are  liable  to  assume  a peculiar  state  of  chronic  in- 
flammation, aflPecting  more  or  less,  sometimes  very  considerably,  the 
convoluted  and  central  surfaces  of  the  brain.  Of  this  morbid 
change  the  first  effects  are  more  or  less  weight,  uneasiness,  and  pain 
of  the  head ; sometimes  partial  convulsive  motions ; sometimes  te- 
tanic motions  or  involuntary  contractions,  vertigo,  double  vision, 
spectral  delirium,  and  occasionally  sudden  loss  of  sensation  and  mo- 
tion. In  other  instances,  it  induces  gradually  deficient  memory, 
disordered  intellect,  and  some  aflrection  of  the  muscles  of  speech. 
Finally,  it  induces  palsy,  fatuity,  and  stupor  or  coma,  terminating 
fatally. 

Palsy  occurring  under  these  circumstances  in  the  insane  is  dis- 
tinguished by  peculiar  characters.  At  first  the  motions  of  the 
tongue  are  constrained;  the  efforts  to  speak  are  unavailing;  arti- 
culation is  impracticable  ; and  the  individual  struggles  and  stam- 
mers to  express  his  desires  like  a person  under  the  influence  of  in- 
toxication. As  this  becomes  intense  he  is  observed  to  totter,  stagger, 
or  reel  in  walking,  and  is  aware  that  he  cannot  direct  the  muscles 

of  the  limbs  to  move  as  he  wills.  At  this  time  the  derangement 

3 


CEREBRAL  SEROUS  MEMBRANE — HEMORRHAGE.  729 


verges  to  fatuity.  At  a more  advanced  period,  not  only  is  speech 
obliterated  or  converted  into  inarticulate  muttering,  but  the  patient 
is  unable  to  maintain  himself  erect ; and  whenever  he  wills  to  make 
any  motion,  neither  arms  nor  legs  are  obedient  to  his  desires.  This 
morbid  action  of  the  cerebral  membranes,  in  short,  impairs,  but  does 
not  annihilate  the  motions  of  all  the  voluntary  muscles.  It  induces 
a general  but  incomplete  loss  of  power. 

The  senses  are  at  the  same  time  impaired  but  not  obliterated. 
The  paralytic  madman  distinguishes  light  from  darkness ; he  hears 
a loud  sound  made  at  the  ears ; and  he  is  sensible  of  pungent 
odours.  But  if  the  skin  be  touched  with  two  bodies,  the  one  hot 
and  the  other  cold,  he  distinguishes  no  difference.  Taste  and  ge- 
neral sensation  are  equally  obtuse.  In  this  state  death  is  not  re- 
mote. The  duration  of  the  affection  varies  according  to  the  slow- 
ness or  rapidity  of  the  meningo-encephalic  disorder,  from  which 
the  palsy  arises.  Some  paralytic  maniacs  live  eight  months,  a 
year,  eighteen  months,  and  others  continue  two  or  three  years, 
rarely  longer.  The  average  duration  of  life,  after  the  commence- 
ment of  paralytic  symptoms  indicates  affection  of  the  cerebral  sur- 
faces extending  to  the  substance,  is  about  thirteen  months. 

II.  Hemorrhage. — Discharges  of  blood  from  the  serous  mem- 
branes have  not  attracted  so  much  attention  as  those  of  the  mu- 
cous surfaces.  They  are  nevertheless  not  uncommon  ; and  though 
the  inaccessible  situation  of  the  serous  surfaces  has  made  their  he- 
morrhages be  overlooked  or  confounded  with  other  diseases,  they 
constitute  a form  of  morbid  action  too  important  to  be  omitted. 
They  occur  in  all  the  serous  membranes,  are  preceded  by  injection, 
and  take  place  by  exhalation,  and  may  be  arranged  in  the  follow- 
ing order. 

Cerebral  membranes,  Mewingmfda. 

Pleura,  Pleurosmia,  Hcemaihorax. 

Pericardium,  Hwmacardia. 

Peritonaeum,  Hcementeria. 

PerididjTnis,  Hceimatorchis. 

§ 1.  MeningcBmia. — The  nature  of  the  subject  compels  me  re- 
luctantly to  begin  with  hemorrhage  of  the  tomentose  or  vascular 
surface  of  the  pia  mater.  In  this  variety  of  meningeal  hemorrhage, 
which  has  been  greatly  overlooked,  the  vessels  of  the  attached  sur- 
face of  the  pia  mater  become  inordinately  injected  and  effuse  blood, 
which  is  deposited  in  the  convoluted  surface  generally,  and  occa- 
sionally in  the  ventricles.  Omitting  some  obscure  accounts  of  this 


730 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


affection  in  the  older  collections,  the  first  good  example  is  given 
by  Morgagni  from  Valsalvi,  who  found  in  the  body  of  a man  of  58 
much  coagulated  blood  between  the  pia  mater  and  the  convoluted 
surface  of  the  right  hemisphere.  (Epist  ii.  19.)  Two  similar  cases 
Morgagni  inspected  himself.  (Epist.  iii.  2 and  4.) 

The  best  instance  of  this  hemorrhage,  however,  is  given  by  Mr 
Howship  in  his  11th  case.  It  occurred  in  a young  woman  of  22, 
who  for  two  years  had  laboured  under  rheumatic  ailments,  and  at 
length,  after  paralytic  and  vertiginous  symptoms,  died  lethargic. 
Upon  inspection  the  pia  mater  yms  found  vascular  and  red;  its  ves- 
sels increased  in  number  and  size ; and  blood  was  diffusely  ex- 
travasated  all  under  the  pia  mater.  ‘‘  The  extravasated  fluid  had 
formed  superficial  coagula,  corresponding  to  the  suki  between  the 
convolutions.” — “ It  had  taken  place  very  universally,  and  the  ef- 
fusion seemed  to  have  arisen  not  only  from  the  capillary  arteries 
upon  the  external  surface  of  the  pia  mater but  also  from  those 
processes  of  the  membrane  which  dip  between  the  convolutions 
forming  the  tomentum  cerebri.  Several  of  these  deep-seated  coa- 
gula were  divided  by  the  knife  in  the  course  of  the  dissection.”* 

Slighter  examples  of  partial  extravasation  on  the  convoluted 
surface  I have  seen  myself,  and  mentioned  many  years  ago,f  when 
I did  not  well  understand  the  source  of  the  hemorrhage.  These 
partial  extravasations  are  the  cause  of  the  orange-coloured  de- 
pressed spots  often  seen  on  the  convoluted  surface  of  the  brain.  Dr 
Abercrombie  records  two  instances  communicated  by  Dr  Hunter 
and  Dr  Barlow,  in  which  the  extravasation,  he  states,  was  from 
the  superficial  vessels  of  the  brain.|  He  does  not  specify,  how- 
ever, whether  the  blood  was  beneath  the  pia  mater  or  above  it.  If 
it  was  above,  it  belongs  to  the  following  head. 

The  lesion  now  described  is  to  be  regarded  as  a hemorrhage 
taking  place  spontaneously.  Much  more  frequently,  however,  blood 
effused  between  the  pia  mater  and  surface  of  the  brain  is  the  effect 
of  blows,  violence,  and  similar  injuries.  As  such  it  has  already 
come  under  consideration ; and  I have  only  to  repeat  what  was 
formerly  stated,  that  in  a medico-legal  point  of  view  the  distinction 
is  most  important,  and  the  correct  knowledge  of  it  may  often  affect 

* Practical  Observations  on  Surgery  and  Morbid  Anatomy,  &c.  Lond.  1816.  Sec- 
tion ii.  Case  xiv.  See  also  cases  xviii.  and  xx. 

t On  the  Pathological  Anatomy  of  the  Brain  and  its  Membranes,  Med.  and  Surg. 
.Journal,  Vol.  xviii.  p.  487. 

Researches,  Pathological  and  Practical. 


" CEREBRAL  SEROUS  MEMBRANE — MENINGEAL  HEMORRHAGE.  731 


the  life  of  a fellow-creature.  In  general,  therefore,  it  is  to  be  un- 
derstood that  when  blood  is  effused  between  the  pia  mater  and  con- 
voluted surface  of  the  brain,  or  within  the  ventricles,  it  proceeds 
from  the  membranes,  and  is  most  likely  to  be  the  result  of  external 
violence.  When,  on  the  other  hand,  the  effusion  is  found  within 
the  substance  of  the  brain,  in  fissures  or  lacerations,  it  is  the  result 
of  disease. 

In  the  hemorrhage  of  the  brains  of  new-born  infants,  tbe  blood 
is  also  situate  between  the  pia  mater  and  brain.  To  this  subject, 
however,  I need  not  recur. 

Hemorrhage  from  the  free  surface  of  the  arachnoid  mem- 
brane is  more  common.  It  may  take  place  either  from  that  which 
lines  the  dura  mater,  and  covers  the  pia  mater,  w'hen  it  is  found 
between  these  two  membranes ; or  from  the  arachnoid  of  the  choroid 
plexus,  when  it  is  found  in  the  ventricles.  Of  the  former,  a good 
instance  is  given  by  Haslam,  who  found  this  the  cause  of  sudden 
death  in  the  person  of  a maniac.  The  same  change  was  found  by 
Bayle  in  about  ^th  of  the  cases  of  persons  cut  off  by  symptoms  of 
chronic  meningitis.  The  cases  of  Drs  Hunter  and  Barlow  are 
already  mentioned. 

Effusion  from  the  interior  or  central  arachnoid  is  more  frequent ; 
and  cases  may  be  found  in  the  writings  of  most  collectors.  Of  this 
nature  are  the  following.  The  case  of  the  chamberlain  of  the  mo- 
nastery of  Rheinau,  near  Schaffhausen,  recorded  by  Wepfer;* 
several  described  by  Morgagni,  e.  g.  the  case  of  Cardinal  Sanvitali ; 
and  those  in  the  13th,  15tb,  17th,  19th,  and  22d  sections  of  his 
second  epistle ; the  cases  of  Antonio  Tita,  Pietro  Facciolati,  and 
the  Danish  ambassador  in  his  third  epistle,  and  one  or  two  in  the 
sixtieth  ; the  case  related  by  Veratti  in  the  Bologna  Memoirs  ;f  the 
case  by  De  Haen,  called  rupture  of  the  choroid  plexus  the  48th  of 
Rochoux  ;§  the  4tb,  8th,  and  12th  cases  of  Cheyne;l|  one  or  two 
cases  by  Merat  and  tbe  20th  and  21st  cases  of  Serres.** 

In  all  these  cases,  blood  or  bloody  fluid  was  found  in  the  ven- 
tricles ; and  since  it  was  not  connected,  as  in  the  ordinary  instances 
of  this  with  rupture  or  injm-y  of  the  cerebral  substance,  and  conse- 
quently had  not  penetrated,  as  I have  formerly  shown,  from  the 
substance  of  the  hemispheres,  it  is  inferred  that  it  must  have  issued 

* Historia  Apoplecticorum.  f Comment.  Bonon.  Tom.  ii.  Chap.  i. 

t Rat.  Med.  Pars  iv.  cap.  v.  p.  189.  § Recherches  sur  I’Apoplexie. 

II  Cases  of  Apoplexy  and  Lethargy.  Lond.  1812. 

H Memoires  de  la  Societe  Medicale  d’Emulation,  Tome  vii.  p.  61. 

* * Annuaire  Medico-Chirurgicale,  &c. 


732 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


from  the  plexus.  There  is  no  reason  to  suppose  that  the  vessels  of 
this  web>re  ruptured  in  this  form  of  hemorrhage.  The  fluid  is 
rarely  pure  blood,  generally  sanguinolent ; but  even  if  pure,  the 
observations  of  Bichat,  Merat,  and  Serres,  show  that  it  may  ooze 
by  exhalation  from  the  plexus.  It  constitutes  the  meningeal  apo- 
plexy of  Serres.* 

The  causes  of  this  form  of  hemorrhage  are  often  as  obscure  as 
those  of  hemorrhage  in  the  substance  of  the  brain.  Yet  in  certain 
cases  it  is  possible  to  trace  a connection  between  these  hemorrhages 
and  the  state  of  the  arteries,  exactly  as  in  hemorrhage  into  the 
substance  of  the  brain.  For  this  reason,  it  is  proper,  in  order  to 
complete  the  pathology  of  cerebral  hemorrhage,  to  advert  to  the 
state  of  the  blood-vessels  which  are  conveyed  along  the  membranes 
of  the  brain. 

§ 2.  Effects  of  the  Steatomatous  and  Osteo-steatomatous  Degene 
ration  of  the  Cerebral  Arteries  on  the  Circulation  of  the  Brain  and 
its  Membranes. — Though  to  this  change  as  a predisposing  cause  to 
softening  and  hemorrhage  I have  already  adverted,  it  may  not  be 
improper  to  take  in  this  place  a general  view  of  the  transformation 
and  its  several  effects. 

The  tunics  of  the  arteries  of  the  brain  are  liable,  in  advanced 
life,  to  become  penetrated  with  steatomatous  and  osteo-steatomatous 
matter  to  an  extreme  degree  and  a very  general  extent.  They 
then  become  rigid,  unyielding,  opaque,  inelastic,  and  are  no  longer 
capable  of  conveying  the  blood  as  pliant  transmissile  tubes.  Though 
this  change  affects  most  usually  the  internal  carotid  and  its  branches, 
as  the  Sylvian  artery,  the  anterior  communicating  arteries,  and  the 
circle  of  Willis,  and  next  to  these  the  basilar  artery,  yet  it  may  ex- 
tend over  all  the  arteries  of  the  brain,  great  and  small.  In  an  ex- 
treme and  extensive  example  of  the  disease  in  my  collection,  the 
whole  of  the  trunks  and  branches  of  the  internal  carotid  and  basilar 
arteries  have  become  completely  penetrated  and  transformed  by 
this  cliange,  and  show  its  effects  in  various  modes.  In  some  parts 
the  arteries  are  enlarged  in  external  circumference,  without  increas- 
ing the  internal  capacity,  and  often  diminishing  it,  in  consequence 
of  the  deposition  between  the  middle  and  inner  coats.  In  all  parts, 
the  internal  area  of  the  arteries  is  more  or  less  diminished ; in 
some  it  is  contracted  so  much,  that  the  canal  of  the  vessel  appears 

* On  Extravasations  of  Blood  into  the  cavity  of  the  Arachnoid,  and  on  the  forma- 
tion of  the  False  Membrane  which  sometimes  envelopes  these  extravasations.  By 
Prescott  Hewett,  Esq.  Medico-Chirurgical  Trans,  vol.  xxviii.  p.  45.  London,  1845. 


CEREBRAL  SEROUS  MEMBRANE — ARTERIAL  DISEASE.  733 


closed,  and  indeed  may  be  closed.  In  some  points  the  vessels  be- 
come tortuous  and  serpentine.  Transverse  sections  also  show  an- 
other change.  The  inner  coat  is  separated  from  the  middle  by  fis- 
sures or  chinks,  caused  apparently  by  the  new  deposition  between 
them ; and  all  over  the  tunics  present  specks  of  steatomatous  or 
osseous  matter,  sometimes  rings  of  bone,  and  in  short  they  are  con- 
verted into  inelastic,  brittle,  and  more  or  less  rigid  tubes. 

The  effects  of  this  state  of  the  cerebral  arteries  on  the  circulation 
are  considerable,  though  not  permanent.  The  blood  is  liable  to 
irregularity  in  its  movement,  and  sometimes  to  become  entirely 
stopped.  In  this  state  the  obstructed  motion  induces  an  attack  of 
cataphora^  or  stupor  and  insensibility,  lasting  for  several  hours,  or 
even  for  one  or  two  days.  In  other  cases  it  induces  a degree  of 
confusion  and  inability  to  walk,  or  keep  in  the  erect  position,  with 
drowsiness,  yet  with  the  patient  being  capable  of  being  roused,  or 
spontaneously  rousing  himself  at  intervals.  After  some  hours  of  rest, 
with  the  use  of  adequate  means,  the  patient  perfectly  recovers,  and 
seems  as  well  in  intellect,  memory,  and  observation,  as  ever.  He 
is  liable,  nevertheless,  to  recurrences  of  these  fits  of  cataphora,  and 
in  one  of  them  death  may  take  place.  Fits  of  this  kind,  neverthe- 
less, I have  seen  come  and  go  in  the  same  individuals  for  several 
years,  apparently  without  affecting  the  health  or  the  intellect,  and 
with  only  a degree  of  impaired  memory.  These  attacks  of  cata- 
phora are  often  mistaken  for  attacks  of  apoplexy ; but  they  are  not 
so,  and  do  not  require  the  same  treatment.  Often,  indeed,  the  pa- 
tient recovers  spontaneously  after  a sound  sleep.  An  awkward 
position  of  the  head  and  neck  occasionally  precedes  these  attacks. 

In  other  instances,  the  osteo-steatomatous  state  of  the  arteries 
produces  more  permanent  and  more  serious  disorder.  By  obstruct- 
ing the  circulation,  it  induces  the  state  formerly  described  as  atro- 
phy of  the  convolutions  and  brain,  often  with  copious  effusion  into 
the  subarachnoid  tissue  and  within  the  ventricles.  In  other  cases 
the  individual  speaks  thick  and  inarticulately,  is  unsteady  in  his 
motions,  and,  though  not  paralytic,  the  limbs  totter  and  shake. 
There  is  also  more  or  less  loss  of  memory.  Such  was  the  state  of 
the  person  whose  cerebral  arteries  I have  above  described  as  ex- 
tensively affected  by  this  transformation. 

Lastly,  from  this  state  of  the  arteries,  evils  still  more  consider- 
able may  result.  It  has  been  observed  several  times  to  give  rise 
to  aneurism  without  or  with  rupture  and  hemorrhage.  Thus  Mr 


734 


GENERAL  AND  PATHOLOGICAL  ANATOMY, 


E.  A.  Jennings  records  in  a stout  healthy  man  of  54,  an  instance 
of  aneurism  of  the  hasilar  artery  suddenly  giving  way,  and  causing 
speedy  dissolution  by  hemorrhage.  This  aneurism,  which  was  about 
the  size  of  a pea,  was  situate  on  the  basilar  artery,  immediately 
after  the  union  of  the  two  vertebral  arteries.  From  this  blood  had 
escaped  and  spread  itself  over  the  medulla  oblongata*  This  per- 
son was  wont  to  suffer  from  pain  in  the  head.  Death  took  place 
about  eight  hours  after  the  appearance  of  the  first  symptoms. 

In  the  course  of  inspections  at  the  Royal  Infirmary  of  this  place, 
I have  observed  three  instances  of  aneurism  of  the  cerebral  arteries 
within  the  space  of  about  five  years.  Two  of  these  were  situate  in 
the  anterior  arteries  of  the  brain  in  the  fissure  of  Sylvius.  The 
arteries  in  both  cases  were  diseased  along  their  whole  course. 
The  aneurismal  swelling  in  one  case  was  about  the  size  of  a pea  ; 
in  the  other  it  was  a little  larger.  In  both  cases,  rupture  had 
taken  place,  followed  by  apoplectic  death. 

A third  case  I observed  in  the  basilar  artery.  The  tumour  here 
was  regularly  spherical,  and  appeared  like  a small  globular  body 
formed  in  the  course  of  the  artery.  The  preparation  is  preserved 
in  the  museum  of  the  university.  A good  example  of  aneurism  in 
the  right  vertebral  artery  is  given  by  Cruveilhier.  In  this  case 
the  swelling  was  almost  exactly  globular,  and  extended  equally  on 
each  side  of  the  artery,  being  altogether  from  five  to  six  lines  in 
diameter.  The  interior  shows  clots  and  steatomatous  deposition. f 

By  some,  as  Mr  Porter,  it  is  maintained  that  aneurism  in  this  si- 
tuation must  be  true  aneurism,  that  is,  formed  by  dilatation  of  the 
inner  and  middle  tunics  alone,  as  there  is  no  cellular  duct  to  form 
an  external  covering,  were  the  inner  tunics  lacerated.  It  is  cer- 
tainly remarkable  that  these  aneurisms  of  the  cerebral  arteries  pre- 
sent examples  of  uniform  and  regular  dilatation  much  more  com- 
plete, than  are  observed  in  the  aneurisms  of  other  regions.  They 
are  in  truth  the  only  aneurisms  which  afford  examples  of  what 
Cruveilhier  denominates  peripheral,  that  is,  spherical  aneurisms, 
embracing  the  entire  periphery  of  the  vessel  in  which  they  are 
formed.  Cruveilhier,  nevertheless,  maintains  that  the  whole  three 
tunics  are  dilated  ; and  in  supporting  this  proposition,  he  necessarily 
maintains  that  the  cerebral  arteries  possess  a cellular  tunic  as  well 
as  those  of  other  regions. 

* Case  of  Aneurism  of  the  Basilar  Artery  suddenly  giving  way,  &c.  By  E.  A.  Jen- 
nings. Transactions  of  Provincial  Association,  Vol.  i.  p.  270.  London,  1833, 

f Anatomic  Pathologique,  Livraison  xxviii.  PI.  iii.  figs.  2,  3,  4. 


CEREBRAL  SEROUS  MEMBRANE n.UMATHORAX. 


735 


§ 3.  It  is  further  an  interesting  confirmation  of  the  view  above  given, 
that  hemorrhage  of  the  same  nature  may  take  place  from  the  arach- 
noid of  the  membranes  of  the  spinal  chord,  and  give  rise  to  similar 
symptoms,  though  modified  by  the  situation  of  the  eflFusion.  Of 
this  variety  of  arachnoid  hemorrhage,  an  instance  is  quoted  by 
Sauvages  from  Duverney,  under  the  title  of  asphyxia  spinalis ; but 
the  best  examples  are  those  recorded  by  M.  Chevalier  in  the  3d 
volume  of  the  Medico-Chirurgical  Transactions,  and  that  by  Sir  A. 
Cooper  in  his  work  on  Dislocation.  In  these  cases  blood,  coagulated 
and  fluid,  was  found  in  the  spinal  canal  between  the  membranes,  and 
the  vessels  of  the  membranes  were  inordinately  loaded. 

§ 4.  PleurcBmia  ; hcemathorax. — On  this  form  of  hemorrhage, 
instances  of  which  are  recorded  by  hlorgagni  and  Lieutaud,  which 
has  been  well  described  by  Merat  and  Laennec,  it  is  unnecessary  to 
say  more.  Merat  informs  us  that  this  hemorrhage  proved  fatal  to 
Professor  Mahon.* 

§ 5.  Hcemacardia,  or  hemorrhage  from  the  pericardium,  has  been 
not  less  overlooked  than  the  ether  bloody  discharges  of  the  serous 
membranes.  In  the  few  instances  which  have  been  recorded,  it  has 
generally  been  ascribed  to  laceration  or  ruptm’e  of  the  auricles, 
venous  sinuses,  or  organs  of  the  large  vessels,  allowing  the  blood 
contained  to  escape  and  distend  the  pericardium.  In  the  instances 
to  which  I now  advert,  the  most  minute  and  diligent  search  was  in- 
adequate to  detect  either  rupture,  laceration,  or  minute  orifices  by 
which  blood  could  escape ; and  it  must  therefore  be  inferred,  that 
it  issues  from  the  membrane  by  the  process  of  exhalation. 

Of  this  singular  hemorrhage,  four  distinct  and  authentic  cases 
are  recorded.  In  the  first,  by  Dr  Alston,  three  pounds  of  coagu- 
lated blood  and  bloody  serum  were  taken  from  the  pericardium. 
When  the  inner  surface  of  the  pericardium,  and  the  external  sur- 
face of  the  heart  were  carefully  cleansed  by  sponges,  no  aperture  of 
any  of  the  large  vessels  could  be  discovered ; “ but  on  pressing  the 
heart  bloody  serum  oozed  from  many  small  orifices  on  its  surface, 
and  principally  near  its  basis. ”f  The  second  case,  by  Dr  Thomson 
of  Worcester,  is  similar  in  the  quantity  and  kind  of  blood  eflfused, 
and  in  the  impossibility  of  tracing  it  to  rupture  or  open  vessel.  | In 
the  third  case,  by  ]\Ir  Joseph  Hooper,  about  five  pints  of  fluid 
blood  perfectly  free  from  coagula^  were  found  in  the  pericardium, 
in  which  no  vestige  of  rupture  could,  after  the  most  careful  exami- 

• Journal  cle  Medecine,  Tome  ix.  p.  132. 

t Medical  Essays  and  Observations,  Vol.  vi.  p.  111.  Art.  hi. 

?;  Medical  Observations  and  Inquiries,  Vol.  iv.  p.  330,  Art.  xxvi. 


736 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


nation,  be  found.*  Lastly,  in  a case  by  Herat,  two  ounces  of  pure 
blood  were  found  in  the  pericardium  of  a man  of  53,  who  had  la- 
boured under  organic  lesion  of  the  heart  and  consecutive  dropsy.f 

Baillie,  to  whom  these  effusions  were  known,  was  aware  of  the 
difficulty  of  explaining  them,  and  conjectures  that  the  blood  may 
have  oozed  by  transudation,  or  escaped  from  the  extremities  of  the 
minute  vessels,  which  he  supposes  may  be  inordinately  relaxed.^ 
The  last  supposition,  it  may  be  remarked,  virtually  admits  exhala- 
tion. 

It  must  be  observed,  nevertheless,  that  the  arteries  on  the  sur- 
face of  the  heart  are  often  diseased  in  this  hemorrhage. 

§ 6.  H(Bmenteria,  PeritonoBmia. — Peritoneal  hemorrhage  is  not 
uncommon.  It  occurs  under  two  forms,  the  sanguinolent  and  the 
sanguine.  A valuable  instance  of  this  hemorrhage,  mentioned  by 
Morgagni, § is  that  of  Laelio  Laelii,  a medical  student,  a native 
of  his  own  town  of  Imola,  in  whose  abdomen  was  found  about  lA 
pound  of  fluid  blood,  with  black  spots  of  the  peritonaeum.  The 
best  examples,  however,  are  those  recorded  by  Herat.  In  the  first, 
there  were  three  pints  of  bloody  serum  in  the  cavity,  with  evident 
marks  of  peritoneal  inflammation.  In  a second,  there  were  between 
two  and  three  pints,  and  the  membrane  was  covered  with  numerous 
granulations.  It  is  reasonable  to  infer  that  this  was  tubercular 
disease  of  the  peritoneum  causing  hemorrhage.  In  a third  case, 
in  which  death  took  place  47  days  after  the  first  symptoms,  upon 
inspection  there  were  found  about  twenty  pints  of  a fluid,  first 
sanguinolent,  then  like  pure  blood,  and  lastly  some  clots.  The 
marks  of  inflammation  were  so  intense  as  to  leave  few  traces  of  the 
original  form  of  the  abdominal  viscera.  || 

§ 7.  Hcematorchis. — Of  hemorrhage  from  the  vaginal  coat,  Bichat 
states  that  he  met  with  two  instances  only  ; and  Herat  acknowledges 
that  he  has  not  yet  seen  any  example.  On  some  occasions  this 
hemorrhage  lays  the  foundation  of  the  bloody  tumour  (Ji(Bmatoma^) 
occasionally  found  in  the  vaginal  coat. 

From  the  facts  recorded  it  results  that  these  hemorrhages,  like 
those  of  the  mucous  tissue,  are  the  result  of  exhalation.  Bichat 
states,  that  after  scrupulous  examination  of  the  inner  surface  of  the 
pleura,  pericardium,  and  peritoncBum,  under  these  hemorrhages,  he 
found  the  surface  entire,  and  the  vessels  unbroken.  There  is  every 

* Memoirs  of  the  Medical  Society,  Vol.  i.  p.  238,  Art.  xviii. 

t Memoires  de  la  Societe  Medicale  d’Emulation,  Vol.  vii.  p.  63. 

X Morbid  Anatomy.  § Epist.  xxxv.  2.  Case  of  Laelio  Laelii. 

II  Memoires  de  la  Societe  Medicale  d’Emulation,  Tom.  vii.  p.  6H. 


SEROUS  MEMBRANE — TUBERCLES, 


737 


reason  to  believe  that  they  are  in  all  cases  preceded  hy  congestion 
of  the  capillaries ; for  most  of  those  which  are  hitherto  accurately 
recorded  were  connected  with  marks  of  inflammation,  and  some  with 
organic  lesion. 

I have  yet  to  observe,  that  the  serous  membranes  are  liable  to 
become  simultaneously  the  seat  of  hemorrhage  in  land-scurvy  and 
in  sea-scurvy.  In  the  former  disease,  these  membranes  have  been 
found  occupied  not  only  by  petechial  spots  and  dark  or  livid  blotches, 
but  with  considerable  effusion  of  fluid  blood.  Of  this,  the  cases  of 
Dr  Duncan  Junior  and  Mr  William  Wood  are  the  best  examples. 
In  extreme  cases  of  scurvy  the  same  extravasation  takes  place. 

III.  Dropsies. — Of  abnormal  accumulation  of  serous  fluid  within 
the  serous  membranes  I have  nothing  to  add  to  what  is  already  said 
in  the  chapter  on  the  exhalants.  These  accumulations  may  almost 
invariably  be  traced  to  disease  of  the  contained  organs,  or  of  other 
organs,  as  the  heart,  liver,  kidneys,  or  tubercular  deposit  in  the 
membranes. 

IV.  Air  is  not  unfrequently  effused  into  cavities  formed  by  serous 
tissue.  Besides  the  form  of  pneumothorax^  which  results  from  fistu- 
lous opening  of  the  lung,  another  may  take  place  from  laceration 
or  wound  of  the  lung.  In  the  peritonaeum  it  is  the  result  either  of 
inflammation,  of  gangrene  and  decomposition  of  serum,  of  ulcera- 
tive perforation,  or  of  organic  disease  producing  the  same  effect. 

V.  Tubercles. — Tubercular  deposition  of  different  kinds  is  fre- 
quent in  the  serous  membranes.  The  exact  nature  of  the  deposi- 
tion, however,  is  not  well  defined.  The  tubercular  diseases  occur- 
ring in  serous  membranes  are  of  two  sorts,  the  genuine  tyromatous^ 
or  that  in  which  tyromatous  matter  is  deposited,  in  irregular  or 
amorphous  masses  in  the  membrane, — and  the  cenchroid  or  miliary, 
in  which  minute  lenticular  bodies  hard  as  cartilage,  but  opaque  or 
semi-transparent,  are  developed  in  these  membranes. 

§ 1.  The  tyromatous  deposition  occurs  in  these  membranes,  but 
most  frequently  in  the  peritonaeum,  in  which  it  was  originally  ob- 
served by  Morgagni,  Lieutaud,  and  Baillie,  afterwards  well  described 
by  Dr  Baron,  and  Scoutetten,  and  observed  by  Dr  MoncrieflT. 
They  are  round  bodies,  varying  in  size  from  a vetch  or  garden-pea 
to  a bean,  not  always  regular  in  shape,  of  caseous  consistence,  and 
generally  softened  in  the  centre.  They  cause  inflammation  of  the 
membrane.  In  the  pleura  tubercles  are  noticed  by  Morgagni,  Lieu- 

3 A 


738 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


taud,  and  Baillie.  To  this  head,  perhaps,  we  may  refer  a variety  of 
tyromatous  tumour  of  the  pleura  observed  by  Mr  Howship.  It  con- 
sisted in  a great  number  of  bulbous  processes  variable  in  shape  and 
size,  but,  apparently  from  the  description,  oblong,  spheroidal,  and 
attached  by  narrow  stalks  or  peduncles.  The  substance  of  these 
bodies,  which  was  semitransparent  and  very  firm,  of  a dull-yellow 
colour,  partly  fluid  and  partly  solid,  is  ascribed  by  Mr  Howship  to 
effusion  of  lymph.  The  opacity  and  increase  of  density  resulting 
from  immersion  in  alcohol  showed  that  they  contained  albuminous 
matter.* 

In  the  membranes  of  the  brain  they  seem  to  be  also  not  uncom- 
mon, though  their  origin  from  the  arachnoid  is  not  quite  established. 

Tubercles  or  tyromatous  depositions  in  the  tubercular  form  are 
often  found  in  the  pia  mater ^ and  especially  its  cerebral  prolonga- 
tions. They  occur  not  only  in  the  exterior  division  of  the  mem- 
brane, but  in  that  which  penetrates  the  ventricles ; and  from  this 
circumstance  it  often  happens  that  tyromatous  bodies,  which  are 
found  in  the  cerebral  substance,  have  originated  in  the  membranes. 
Thus  of  the  figures  given  by  Baillie  in  the  7th  pi.  of  his  10th  fasci- 
culus, two  tubercular  bodies  are  found  actually  attached  to  the  cho- 
roid plexus ; one  found  in  the  lower  part  of  the  fourth  ventricle  ; 
and  that  represented  by  Dr  Hooper  in  the  same  situation  (12th 
pi.)  appears  to  have  had  the  same  origin  ; and  those  said  to  be  found 
in  the  brain  were  very  probably  originally  formed  at  the  filamentous 
surface  of  the  pia  mater,  between  which  and  the  bodies,  in  most  in- 
stances, vascular  connections  are  distinct  and  immediate. 

§ 2.  The  cenchroid  tubercles  are  very  frequent  in  serous  tissue. 
In  the  pleura  they  wei’e  seen  by  Wrisberg,  Baillie,  Bayle,  Laennec, 
and  Andral ; in  the  peritonaeum  by  Scoutetten. 

These  miliary  or  cartilaginous  tubercles  are  not  unfrequently 
found  to  occupy  all  the  serous  membranes  at  once,  more  especi- 
ally in  the  bodies  of  the  lower  animals.  Thus  I have  often  seen 
them  in  the  pleura,  pericardium,  and  peritonaeum  in  the  sheep ; 
and  in  a specimen  of  the  Paca  dissected  by  my  friend  Dr  Grant, 
every  serous  membrane  was  thickly  set  with  them.  They  occur 
chiefly  in  men  and  animals  long  excluded  from  air  and  exercise. 
In  the  early  stage  they  do  not  exercise  much  influence  on  the  state 
of  these  membranes.  But  at  a more  advanced  period  they  cause 
inordinate  exhalation,  opacity,  dulness,  and  other  marks  of  morbid 
circulation  of  the  tissue. 

■*  Practical  Observations  on  Surgery  and  Morbid  Anatomy,  p.  204. 


SEROUS  MEMBRANE — TUBERCLES. 


739 


In  the  human  body  cenchroid  tubercles  occur  in  the  pleura  and 
peritoneum  in  two  forms. 

In  one,  very  small  bodies  like  the  heads  of  needles  or  pins,  and 
generally  of  a white  colour,  are  disseminated  over  the  whole  pleu- 
ral or  peritoneal  surface.  These  are  very  closely  set,  and  com- 
municate to  the  membrane  a perceptible  degree  of  roughness. 
After  some  time  they  cause,  at  least  in  the  peritonaeum,  adhesion 
of  the  folds  of  the  ileum,  so  that  the  whole  bowels  are  united  in  one 
general  adherent  mass.  These  tubercles  are  seated  in  the  substance 
of  the  peritonaeum.  They  do  not  appear  to  increase  much  in  size, 
but  they  tend  simply  to  induce  chronic  inflammation  of  the  mem- 
brane and  union  of  Its  parts  by  efiusion  of  lymph  and  adhesion. 

They  likewise  tend  to  cause  the  efiusion  of  serous  fluid  from  the 
surface  of  the  peritoneum. 

In  the  second  variety,  small  bodies,  a little  larger  than  those 
last  mentioned,  are  most  minutely  and  extensively  disseminated 
over  the  pleura  or  peritoneum.  These  resemble  gunpowder  grains, 
are  generally  of  a light  blue  colour,  and  are  always  extremely  hard. 
They  are  less  liable  to  cause  adhesive  inflammation  than  the  small 
white  tubercles.  Yet  occasionally  the  intestinal  peritonaeum  is  ob- 
served adhering  extensively,  in  consequence  of  their  development 
in  that  membrane. 

They  alw'ays  derange  the  circulation  and  secretion  of  the  mem- 
brane ; and  much  serous  fluid  is  accumulated  within  the  cavities  in 
consequence.  They  may  take  place  in  one  serous  membrane  only  ; 
but  they  often  take  place  in  the  pleura  and  peritoneum  at  once, 
causing  in  the  former  hydrothorax,  and  in  the  latter  ascites. 

They  affect  in  the  abdomen,  the  mesentery  and  omentum ; and 
the  latter  is  doubled  or  folded  up  like  an  oblong  tumour  across  the 
abdomen  between  the  stomach  and  colon.* 

In  the  brain  they  are  mostly  seen  in  the  pia  mater  towards  the 
base ; and  they  in  that  situation  resemble  neither  the  first  nor  the 
second  variety  of  tubercles ; being  larger  than  the  former,  and  less 
hard  than  the  latter. 

They  may  take  place  at  any  region  of  the  pia  mater.  But  they 
are  more  common  at  the  base  of  the  brain  and  around  the  cerebel- 
lum than  in  any  other  situation. 

Wherever  they  are  found,  they  induce  chronic  hydrocephalic 

* Report  of  the  Cases  treated  during  the  Course  of  Clinical  Lectures  delivered  at 
the  Royal  Infirmary  in  1832-1833.  By  Uavid  Craigie,  M.  1).  Edin.  Med.  and  Surg. 
Journal,  xli.  122.  Edinburgh,  1834. 


740 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


effusion,  with  symptoms  of  stupor,  coma,  and  sometimes  convul- 
sions, which  terminate  fatally  in  about  six  or  seven  weeks,  sometimes 
earlier. 

The  opinion  of  Laennec,  that  miliary  tubercles  are  the  incipient 
form  of  the  tyromatous  tubercle,  is,  in  reference  to  the  serous  mem- 
branes, destitute  of  proof.  The  miliary  eminences  of  these  mem- 
branes have  not  yet  been  shown  to  pass  into  the  tyromatous. 

VI.  Chondroma. — Cartilaginous  degeneration  is  not  uncommon 
in  the  serous  tissue.  It  appears  in  the  form  of  patches  varying  in 
size  and  shape,  attached  to  the  free  surface  of  the  membranes.  By 
some  authors  this  is  regarded  as  a preliminary  step  to  ossification. 
But  this  is  not  established. 

New  development  of  cartilage  is  most  commonly  seen  in  the 
pleura  and  pericardium  in  the  form  of  bluish-white  patches,  highly 
polished  on  the  free  surface,  varying  from  the  size  of  a fourpenny 
piece  to  the  diameter  of  one  shilling  and  more.  The  margins  of 
these  patches  is  irregular  and  sometimes  indented  and  sending  out 
other  thin  patches. 

In  general  the  formation  of  these  patches  is  preceded  by  inflam- 
mation, subacute  or  chronic,  in  the  course  of  which  the  spot  is 
covered  by  lymph,  which  afterwards  undergoes  the  cartilaginous 
transformation.  Sometimes  the  part  is  puckered  and  shrivelled, 
as  if  previously  the  pulmonic  tissue  had  been  affected  by  inflamma- 
tion. In  old  cases  of  chronic  pleurisy  and  emphysema^  it  is  usual 
for  the  false  membrane  to  be  converted  into  a fibrous  layer  of  im- 
perfect cartilage,  uniting  the  two  pleurae. 

Similar  patches  are  observed  in  the  hepatic  and  splenic  perito- 
nceum  ; the  spleen  may  be  entirely  enclosed  in  a cartilaginous  tu- 
nic ; and  often  the  peritonaeum  covering  the  ovaries  is  entirely 
transformed  into  a firm  though  not  very  thick  cartilaginous  covering. 

VII.  Ossification. — In  no  texture,  perhaps,  is  osseous  deposi- 
tion more  frequent  than  in  the  serous.  It  occurs  in  every  one  of 
these  membranes  without  exception.  In  the  arachnoid  it  is  not 
unfrequently  seen  in  the  form  of  osseous  plates  at  the  inner  surface 
of  the  dura  mater and  the  free  surface  of  the  pia  mater.  Often, 
also,  numerous  thin  scales  of  bony  matter  with  pearly  aspect  are 
observed  in  the  arachnoid  of  the  spinal  canal.  In  the  pleura  and 
pericardium  it  is  exceedingly  common,  instances  of  it  being  no- 
ticed by  most  authors,  and  numerous  specimens  of  it  contained 


SEROUS  MEMBRANE — MORBID  GROATTHS. 


741 


in  museums.  In  the  pleura  it  is  most  common  in  the  costal  divi- 
sion, large  portions  of  which  are  sometimes  found  converted  in- 
to broad  flat  patches  of  bone.  The  instances  of  ossification  of  the 
diaphragm  are  of  the  same  nature.  In  the  pericardium  it  is  pro- 
bably most  frequent  in  the  cardiac  division,  and  constitutes  those 
cases  vaguely  denominated  ossified  hearts.  In  the  peritonaeum  it 
is  less  frequent ; but  is  remarked  in  particular  portions  of  this  mem- 
brane. Thus  it  is  common  in  the  muscular,  diaphragmatic,  splenic, 
and  uterine  peritonaeum,  less  frequent  in  the  hepatic  and  colic,  and 
scarcely  seen  in  the  ileal.  These  patches,  though  hard,  firm,  and 
apparently  solid  like  bone,  never  present  the  organization  peculiar 
to  that  substance.  Their  presence  is  generally  connected  with 
traces  of  inflammation  or  at  least  injection  of  the  membrane ; and 
Rayer,  in  an  elaborate  essay,  attempted  to  prove  that  osseous 
deposition  is  a result  of  that  process.*  Indeed,  many  circumstances 
render  it  highly  probable  that  chronic  inflammation  of  serous  tis- 
sue causes  effusion  of  lymph,  which  is  eventually  converted  into 
osseous  matter.  One  of  the  most  satisfactory  proofs  of  this  principle 
is,  that  osseous  induration  of  the  peritonaeum  is  very  common  in 
hernial  protrusions  of  the  intestine,  in  which  the  membrane  is  sub- 
jected to  slow  inflammation  ; and  that  the  vaginal  coat  of  the  tes- 
ticle is  often  cartilaginous,  or  even  bony  in  cases  of  old  hydrocele. 

VIII.  Morbid  Gtrowths  and  Parasitical  Animals.- — § 1. 
Hygroma. — The  serous  cyst  is  not  uncommon  in  the  diaphanous 
membranes.  It  appears,  however,  from  various  observations,  to  be 
most  frequent  in  the  attached  surface,  or  in  the  subserous  tissue. 

§ 2.  Hydatids.,  Acephalo-cysts. — These  globular  sacs  are  believed 
to  be  almost  proper  to  tbe  serous  membranes.  It  is  certain  that  in 
these  they  are  more  frequently  observed  than  elsewhere.  Thus 
they  are  found  attached  to  the  pleura,  to  the  pericardium,  to  the 
peritonaeum,  and  to  the  vaginal  coat ; and  in  some  rare  cases  they 
have  been  seen  in  the  choroid  plexus.  Thus  Pischer  found  the 
taenia  hydatigena  of  Pallas,  or  the  cysticercus  pyriformis  of  Zeder, 
attached  to  this  membrane  by  a peduncle,  and  vesicular  bodies,  sup- 
posed to  be  of  the  same  genus,  attached  to  the  arachnoid  surface  of 
the  dura  mater.  The  writings  of  Bonetus,  Morgagni,  and  other 
collectors,  contain  frequent  examples  of  pulmonary  hydatids,  seve- 
ral of  which  were  originally  hydatids  of  the  pleura,  and  several  of 

* Archives  Generales,  Tom.  vii. 


742 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  subserous  tissue.  In  the  peritonaeum  they  are  still  more  fre- 
quent ; and  Dr  Monro  tertius  gives  a valuable  collection  of  cases, 
in  which  these  bodies  were  found  connected  with  various  regions  of 
that  membrane.  Though  the  cysticercus  or  solitary  hydatid  is  oc- 
casionally found,  those  more  usually  seen  in  this  membrane  are  the 
ccBnuri  and  echinococci,  or  the  gregarious  form  of  the  animal.  Of 
this  description,  I have  several  times  observed  good  examples.  In 
the  body  of  a man  of  about  45,  who  died  with  the  usual  symptoms 
of  dropsy,  tvvo  globular  cysts,  one  as  large  as  a child’s  head,  were 
found  attached  to  the  hepatic  peritonaeum.  In  each  of  these  were 
contained  an  immense  number  of  globular  cysts  containing  trans- 
parent fluid,  about  half  an  inch  or  eight  lines  in  diameter,  and  sur- 
rounded in  like  manner  by  a transparent  fluid.  Two  similar  cysts, 
each  containing  many  small  ones,  were  found  attached  to  part  of 
the  ileum.  These  were  unequivocal  examples  of  the  acephalo-cyst, 
which  is  indeed  very  commonly  developed  within  and  in  connection 
with  the  peritonaeum.  These  bodies  caused  during  life  irregular 
prominent  tumours  of  the  belly.  Hydatids  are  also  common  in  the 
vaginal  coat, 

§ 3.  Fungus  Hoimatodes  is  observed  to  take  place  in  this  tissue, 
I have  seen  it  affect  the  pleura  in  the  form  of  numerous  pendulous 
and  sessile  tumours.  It  is,  however,  more  common  in  the  perito- 
ncBum,  both  at  its  free  and  at  its  attached  surface.  One  example, 
in  which  it  originated  in  the  hepatic  peritonaeum,  and  thence  pro- 
ceeded to  affect  the  greater  part  of  the  abdominal  cavity,  and  af- 
terwards presented  at  the  groin,  where  it  destroyed  the  bones  of 
the  pelvis,  and  the  upper  end  of  the  thigh-bone,  some  years  ago 
fell  under  my  observation.  The  tumour  had  attained  an  enormous 
size,  and  consisted  chiefly  of  cerebriform  matter  contained  in  seve- 
ral cysts,  and  in  some  instances  softened  into  a dark-coloured  pulpy 
semifluid  mass. 

§ 4.  Scirrhous  induration  is  said  to  take  place  in  serous  tissue. 
There  is  no  doubt  that  it  often  affects  this  tissue  from  the  conti- 
guous ones,  especially  the  mucous  and  submucous ; but  it  is  not 
ascertained,  that  it  originates  in  the  serous  membrane.  It  is  not 
necessary  to  confound  under  this  name  various  indurations,  which 
seem  to  be  the  result  of  the  inflammatory  process,  or  the  lardaceous 
state  observed  in  the  omentum  and  mesentery  in  old  dysenteries, 
which  by  some  have  been  represented  as  examples  of  this  morbid 
degeneration. 


4 


FIBRO-SEROUS  MEMBRANE — CHRONIC  THICKENING.  743 


IX.  Accidental  Development. — No  tissue  perhaps  is  so  liable 
to  be  accidentally  repeated  as  the  serous.  The  cysts  already  men- 
tioned are  generally  regarded  as  examples  of  this  repetition ; and, 
indeed,  they  possess  all  the  characters  of  serous  tissue.  These 
cysts  are  found  in  many  parts  of  the  body  ; but  they  are  most  fre- 
quently observed  in  the  kidneys,  sometimes  in  connection  with 
granular  disease  of  those  glands;  and  they  are  very  common  in 
the  female  ovary,  in  which  they  often  constitute  the  anatomical 
character  of  dropsy  of  that  organ.  They  are  also  seen  in  the 
testicle  of  the  male.  The  mode  of  their  development  is  not 
well  ascertained.  The  hypothesis  of  dilatation  or  expansion  by 
mechanical  compression  was  successfully  refuted  by  Bichat;  but 
the  one,  which  he  attempts  to  establish  in  its  place,  has  not  been 
generally  adopted. 

Certain  of  the  minute  clustered  bodies  denominated  by  Laennec 
acephalo-cysts,  and  the  animal  nature  of  which,  though  admitted 
by  that  author,  is  denied  by  Cuvier  and  Rudolphi,  belong  to  the 
same  head.  Their  formation  is  equally  little  understood. 

X.  Morbid  States  of  the  Fibro-serous  Membranes. — Be- 
fore concluding  this  chapter,  I must  notice  certain  morbid  states 
incident  to  the  fibro-serous  membranes. 

§ 1.  The  dm-a  mater,  as  a compound  membrane,  partaking  at  once 
of  the  structure  of  periosteum  and  arachnoid,  is  liable  to  affections 
which  bear  this  twofold  character.  Its  outer  or  cranial  lamina  is 
liable  to  all  the  morbid  processes  incident  to  periosteum.  Its  in- 
ner or  arachnoid,  it  has  been  already  shown,  is  liable  to  those  pe- 
culiar to  this  membranous  pellicle. 

I have  already  shown  that  the  latter  surface  of  the  dura  mater  is 
occasionally  covered  by  albuminous  exudation,  the  result  of  the  in- 
flammatory process.  This  same  substance  is  occasionally  deposited 
between  its  laminae,  and  causes  thickening  and  some  induration. 

§ 2.  Thickening  of  the  Dura  Mater. — This  membrane  is  liable, 
under  the  influence  of  various  causes,  to  become  greatly  thickened. 
In  several  instances  I have  seen  it  as  thick  as  ordinary  leather,  very 
firm,  yet  otherwise  unchanged  in  structure.  This  thickening  is 
always  connected  with  symptoms  of  chronic  inflammation,  which 
may  take  place  either  spontaneously  or  in  consequence  of  external 
violence  on  the  head.  Yet  the  thickening  is  usually  confined  to 
the  dura  mater  of  one  hemisphere,  and  that  the  superior  part  of  the 


744 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


brain ; and  it  terminates  gradually  in  the  membrane,  presenting  its 
wonted  character  at  the  base  of  the  organ.  The  dura  mater  of  the 
opposite  hemisphere  is  in  general  natural. 

In  one  spontaneous  case,  in  which  I found  this  thickening,  the 
person  during  life  was  so  addicted  to  the  use  of  spirits,  that  he  was 
rarely  sober,  or  at  least  quite  correct.  He  was  in  the  practice  of 
speaking  aloud  to  himself  in  the  streets,  and  had  a habit  of  jerking 
his  head  to  the  side  from  time  to  time  as  he  walked.  He  died  at 
last  of  symptoms  of  injury  of  the  back  and  posteriors  from  a fall, 
and  with  them  were  mingled  symptoms  of  delirium  tremens. 

Most  commonly,  nevertheless,  this  lesion  is  the  result  of  external 
violence.  In  one  well-marked  case  which  fell  under  my  own  no- 
tice, and  in  which  I carefully  inspected  the  parts  after  death,  the 
first  exciting  cause  was  a fall  down  stairs  in  a state  of  intoxication, 
in  which  the  individual  struck  the  head  on  the  steps.  He  was  car- 
ried home  in  a state  of  insensibility,  and  in  that  he  continued  for 
nine  days.  He  then  began  to  show  signs  of  returning  conscious- 
ness ; and  began  to  take  food  and  drink,  and  live  a sort  of  vege- 
table existence.  This  state  improved  a little.  But  memory,  judg- 
ment, and  all  the  mental  faculties  were  entirely  gone.  The  patient 
recovered  consciousness  and  a degree  of  sensibility,  only  to  remain 
a paralytic  idiot  for  life.  This  state  continued  between  two  and 
three  years,  when  death  ensued. 

The  dura  mater  of  the  left  hemisphere  was  then  found  very  much 
thickened.  The  sub-arachnoid  tissue  was  infiltrated  with  serous 
fluid  to  a very  great  amount.  The  convolutions  were  very  much 
atrophied.  About  four  ounces  of  serous  fluid  were  contained  with- 
in the  ventricles,  the  cavities  of  which  were  dilated,  and  the  walls 
extruded. 

The  fornix  was  softened ; the  septum  lucidum  entirely  destroyed; 
and  in  its  place  was  a large  elliptical  aperture,  by  which  the  ven- 
tricles communicated  freely  and  directly  with  each  other. 

Such  are  the  eflPects  of  chronic  inflammation  continued  through 
a long  period  before  they  prove  fatal. 

§ 3.  Tyroraatous  deposition  in  round  nodules  also  occurs  in  this 
membrane,  and  has  been  well  represented  by  Dr  Hooper  in  his  6th 
and  7 th  engravings.  They  possess  all  the  characters  of  the  usual 
tyromatous  matter,  and  consist  of  whitish  or  gray  opaque  substance 
of  the  consistence  of  cheese,  of  different  degrees  of  firmness,  inclosed 
in  a vascular  capsule.  Generally  they  grow  from  the  arachnoid 

5 


FIBRO-SEROUS  MEMBRANE. 


745 


surface  of  the  membrane,  but  sometimes  they  seem  to  arise  from 
its  substance. 

§ 4.  The  dura  mater  oiiQU  becomes  the  seat  of  a firm  tumour,  which, 
as  it  grows,  produces  absorption  of  the  cranial  bones.  In  the  ex- 
cellent collection  of  cases  by  M.  Louis,  we  find  that  it  invariably 
proceeded  to  bad  ulceration ; but  that  death  in  general  took  place 
in  consequence  of  interruption  to  the  functions  of  the  brain. 

§ 5.  In  the  testicle  I have  seen  a peculiar  disease  which  I refer  to 
the  albuginea  and  its  serous  covering.  The  testicle  seems  much 
enlarged  and  irregular;  but  shortly  ulceration  takes  place,  and 
discloses  an  extensive  mass  of  dead  matter  evidently  exterior  to  the 
gland.  The  sloughing  process  alternating  with  ulceration  and  gra- 
nulation proceeds  till  the  whole  exterior  coat  of  the  testicle  is  ex- 
pelled. This  process,  which  occurred  in  a scrofulous  subject,  and 
never  showed  any  tendency  to  malignant  ulceration,  I ascribe  to 
death  of  the  fibro-serous  covering  of  the  testicle,  and  perhaps  of 
the  gland  itself. 

XL  Fibrous  and  Fibro-cartilaginous  Tumours. — Cartilagi- 
nous and  bony  matter  of  different  degrees  of  firmness  and  perfection 
are  often  observed  in  the  cerebral  membranes,  more  especially  the 
dura  mater.  Of  this  change  manifold  instances  are  given  byBonetus, 
Morgagni,  Lieutaud,  Sandifort,  and  other  collectors ; and  they  are 
delineated  by  Baillie  and  Hooper.  These  cases  are  vaguely  men- 
tioned under  the  general  title  of  ossification  of  the  brain ; but  few 
of  them  are  entitled  to  this  character,  for  all  of  these  originate  in 
the  membranes.  The  only  authentic  instance  apparently  of  bony 
matter  found  in  the  substance  of  the  brain  unconnected  with  the 
membranes,  is  that  delineated  by  Dr  Hooper  in  his  12th  engraving. 
The  description,  nevertheless,  is  not  sufficiently  minute  to  justify 
positive  assertion. 


746 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


CHAPTER  IV. 

SYNOVIAL  MEMBRANE. — Memhrana  Si/novialis, — Bursa:  Mucosa. 

Section  I, 

Bichat  enumerates  several  circumstances  in  which  he  conceives 
that  serous  and  synovial  membrane  differ  from  each  other.  Gror- 
don,  who  doubts  how  far  the  distinctions  are  well  founded  as  the 
basis  of  anatomical  arrangement,  admits^  however,  peculiarities 
which  shall  afterwards  be  mentioned. 

Synovial  membrane  resembles  serous  membrane  in  so  far  as  it 
is  a thin,  transparent  substance,  having  one  smooth  free  surface 
turned  towards  certain  cavities  of  the  body,  and  another  connected 
by  delicate  cellular  substance  to  the  sides  of  these  cavities,  or  to 
the  parts  contained  in  them.  But  it  differs  from  serous  membrane 
in  the  following  circumstances,  l.s?.  It  possesses  little  vascularity 
in  the  healthy  state ; no  blood-vessels  are  almost  ever  seen  in  it 
after  death,  nor  can  they  be  made  to  receive  the  finest  injection.  2(7, 
Its  lymphatics  are  quite  incapable  of  demonstration.  Zd,  Very  de- 
licate fibres,  like  those  of  cellular  substance,  or  like  the  finest  fila- 
ments of  tendon,  are  distinctly  seen  in  it  after  slight  maceration. 
47A,  It  is  considerably  less  strong  than  serous  membrane.  On  these 
grounds,  therefore,  synovial  membrane  is  to  be  anatomically  dis- 
tinguished from  serous  membrane. 

The  synovial  membrane,  as  described  above,  is  found  not  only  in 
each  of  the  moveable  articulations,  but  in  those  sheaths  in  which 
tendons  are  lodged,  and  in  which  they  undergo  a considerable  ex- 
tent of  motion,  and  in  certain  situations  in  the  subcutaneous  filamen- 
tous tissue. 

The  distribution  of  the  synovial  membranes  is  much  the  same  in 
all  these  situations.  They  are  known  to  line  the  ligamentous  appa- 
ratus of  each  joint,  capsular  and  funicular  ; and  they  are  also  con- 
tinued over  the  cartilaginous  extremities  of  the  bones  of  which  the 
articulation  consists.  This  continuation,  which  was  originally  main- 
tained by  Nesbitt,  Bonn,  and  William  Hunter,  and  was  demonstrat- 
ed by  various  facts  by  Bichat,  was  afterwards  questioned  by  Gordon 
and  Magendie,  the  former  of  whom  especially  thinks  it  unsuscep- 


SYNOVIAL  MEMBRANE. 


747 


tible  of  anatomical  proof.  The  cartilaginous  synovial  membrane 
is  certainly  not  so  easily  demonstrable  as  the  capsular,  for  the  same 
reason  which  I have  already  assigned  regarding  the  difficulty  of 
isolating  the  arachnoid  of  the  dura  mater,  the  capsular  pericardium, 
the  ovarian  peritonaeum,  and  the  serous  covering  of  the  tunica  al- 
buginea,— the  want  of  filamentous  tissue. 

The  presence  of  synovial  membrane  in  the  articular  cartilage  is 
nevertheless  established  by  sundry  facts.  Is?,  If  a portion  of  arti- 
cular cartilage  be  divided  obliquely,  and  examined  by  a good  glass, 
it  is  not  diflBcult  to  recognize  at  one  extremity  of  the  section  a thin 
pellicle,  differing  widely  in  aspect,  colour,  and  structure,  from  the 
bluish-white  appearance  of  the  cartilage.  2d,  If  the  free  surface 
of  the  cartilage  be  scraped  gently,  it  is  possible  to  detach  thin  shav- 
ings, which  are  also  distinct  from  cartilage  in  their  appearance. 
Zd,  The  free  surface  of  the  cartilage  is  totally  different  from  the 
attached  surface,  or  from  a section  of  its  substance,  and  derives  its 
peculiar  smooth  polished  appearance  from  a very  thin  transparent 
pellicle  uniformly  spread  over  it  Ath,  If  ai’ticular  cartilage  be 
immersed  in  boiling  water,  this  thin  pellicle  becomes  opaque,  while 
the  cartilage  is  little  changed.  5t1i,  Immersion  in  nitric  or  muri- 
atic acid,  which  detaches  the  cartilage  from  the  bone,  gives  this  sur- 
face a cracked  appearance,  which  is  not  seen  in  the  attached  surface, 
and  which  is  probably  to  be  ascribed  to  irregular  contraction  of 
two  diflPerent  animal  substances.  Zth,  The  existence  of  this  carti- 
laginous synovial  membrane  is  demonstrated  by  the  morbid  process 
with  Mdiich  the  tissue  is  liable  to  be  aflTected.  Upon  the  whole, 
therefore,  I believe  little  doubt  can  be  entertained,  that  the  repre- 
sentation of  their  course,  as  given  originally  by  Nesbitt,  Bonn,  and 
Hunter,  is  well  founded. 

The  same  views  may  be  applied  to  the  synovial  linings  of  the 
tendinous  sheaths,  which  are  equally  to  be  viewed  as  shut  sacs. 

Attached  to  the  free  surface  of  each  synovial  membrane  is  a pe- 
culiar fringe-like  substance,  which  was  long  supposed  to  be  an  ap- 
paratus of  glands  (glands  of  Havers)  for  secreting  synovial  fluid. 
It  is  now  known  that  these  fringes  are  merely  puckered  folds  of 
synovial  membrane,  and  that,  although  synovia  is  abundantly  se- 
creted by  them,  this  depends  merely  on  the  great  extent  of  surface 
which  their  puckered  arrangement  necessarily  presents.  This  ar- 
rangement is  easily  demonstrated  by  immersing  an  articulation  con- 
taining the  fringed  processes  in  clear  water,  when  they  are  unfolded 


748 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


and  made  to  float,  and  show  their  connections,  figure,  and  termina- 
tions. They  are  analogous  to  the  free  processes  of  serous  mem- 
branes, and  like  them  are  double,  and  contain  adipose  matter. 

The  synovial  sheaths  (hursce  mucoscB)  are  very  numerous,  and 
are  generally  found  in  every  tendon  which  is  exposed  to  frequent 
or  extensive  motion. 

Though  the  fluid  prepared  by  these  membranes  has  been  exa- 
mined by  Margueron,  Fourcroy,  John  Davy,  Orfila,  Berzelius, 
.John,  and  other  chemists,  it  cannot  be  said  that  very  accurate  re- 
sults have  been  yet  given  of  its  chemical  composition.  It  is  said 
to  contain  water,  albumen,  incoagulable  matter,  regarded  as  muci- 
laginous gelatine,  a ropy  matter,  and  salts  of  soda,  lime,  and  some 
uric  acid. 

Section  II. 

The  diseases  of  synovial  membrane  are  important. 

§ 1.  Hymenarthritis. — Inflammation  is  an  occurrence  not  unfre- 
quent in  the  synovial  tissue,  and  produces  effects  in  many  respects  j 
similar  to  those  which  are  observed  in  the  serous  membranes. 
Every  example  of  diseased  joint,  there  is  reason  to  believe,  com- 
mences with  inflammation,  acute  or  chronic,  of  the  synovial  mem- 
brane. Of  this  process  the  anatomical  characters  are,  injection  of 
the  membrane,  which  sometimes  becomes  very  red  with  numerous 
vessels,  and  occasionally  traversed  by  crimson  or  brown  spots  and 
patches,  dulness  of  its  surface,  opacity,  thickening  to  a considerable 
extent,  and  some  degree  of  pulpiness.  The  effects  of  the  process 
are  effusion  of  fluid,  sometimes  serous,  sometimes  ichorous  or  vi- 
tiated synovia^  more  especially  tinged  with  blood,  occasionally  sero- 
albuminous  fluid,  which  undergoes  partial  coagulation,  and  leaves 
the  cavity  distended  with  a thin  sero-purulent  liquid.  In  other 
instances,  complete  purulent  matter,  with  curdy  or  albuminous 
flakes,  are  the  result  of  synovial  inflammation. 

If  it  fail  to  terminate  in  resolution,  the  fluid  effusion  in  the  syno- 
vial sac  constitutes  the  simplest  of  those  multiform  affections  known 
under  the  name  of  white  swelling  ; (hydarthrus.)  When  this  is  not 
abundant,  the  fluid  part  is  absorbed,  and  the  coagulable  matter 
may  contract  adhesion  to  the  free  surface  of  the  membrane.  This 
is  the  origin  of  that  species  of  ankylosis,  sometimes  general  and 
complete,  sometimes  partial  and  imperfect,  in  which  the  articular 


SYNOVIAL  MEMBRANE — INFLAMMATION  AND  ULCERATION.  749 


synovial  membrane  is  found  united  by  bridles  or  ligaments  of  false 
membrane. 

When  sero-purulent  or  purulent  matter  is  effused  into  a synovial 
cavity,  especially  -where  the  inflammation  fails  to  be  resolved,  or 
passes  into  the  chronic  state,  ulceration  of  the  capsule  and  the  in- 
terligamentous  tissue  is  liable  to  take  place,  and  the  ichorous  or 
sero-purulent  fluid  is  discharged  by  one  or  more  openings  through 
the  skin. 

In  more  advanced  and  chronic  states,  the  synovial  membrane 
often  becomes  thick,  pulpy,  and  vascular,  granular  or  villous  on 
its  surface,  and  is  at  length  destroyed  by  ulceration.  In  some 
joints,  this  process  is  an  immediate  effect  of  inflammation,  the  syno- 
vial covering  being  gradually  perforated  in  numerous  points  at 
which  the  subjacent  cartilage  is  exposed,  and  then  undergoes  ero- 
sion. Though  this  process  may  occur  in  any  joint,  the  researches 
of  Sir  B.  Brodie  show  that  it  is  most  frequent  in  the  knee,  in  which 
the  destruction  it  occasions  is  often  very  great.  A disease  of  this 
kind  I have  several  times  seen  remove  every  particle  of  cartilage 
from  the  articulating  extremities,  and  expose  the  cancellated  struc- 
ture of  the  bone.  This  process  is  attended  with  extreme  pain  and 
sufiering  to  the  patient,  more  particularly  aggravated  during  the 
night.  The  same  process  takes  place  in  the  elbow-joint,  but  here 
it  often  forms  fistulous  abscesses  of  the  extra-capsular  cellular  tissue. 
In  the  articular  processes  of  the  vertebrae,  I have  seen  it  often  give 
rise  to  disease  of  these  bones,  and  finally  terminate  in  ankylosis, 
with  destruction  of  the  processes,  and  considerable  lateral  curvature 
of  the  spine. 

Inflammation  of  the  articular  synovial  sacs  affects  not  only  the 
cartilages  and  bones,  but  the  ligaments,  capsular  and  funicular. 
Its  transition  to  these  textures,  which  is  easy  and  direct,  induces 
thickening  and  induration  of  the  ligament,  in  consequence  of  effu- 
sion of  lymph  between  its  fibres  and  interstices.  After  some  time 
the  action  extends  to  the  extra-articular  filamentous  tissue,  which 
is  then  injected  by  jelly-like  fluid,  sometimes  colourless  or  pale  red> 
at  other  times  reddish  or  brown.  At  the  same  time,  this  filamen- 
tous tissue  acquires  a granular  character  and  some  induration. 
These  several  changes,  which  give  rise  to  swelling  round  the  joint 
more  or  less  diffuse,  constitute  one  of  the  most  frequent  forms  of 
white-swelling.  Suppuration  may  take  place,  as  in  the  last  in- 
stance, followed  by  fistulous  openings. 


,( 


750  GENERAL  AND  PATHOLOGICAL  ANATOMY. 

§ 2.  Velvet-like  Degeneration. — I have  already  mentioned  the  gra- 
nular and  villous  state  of  the  synovial  membrane.  It  is  not  easy  to 
say  whether  the  change  next  to  be  noticed  is  a more  advanced  stage 
of  this  state,  or  is  to  he  viewed  as  a separate  organic  affection. 

Synovial  membrane  is  liable  to  a peculiar  form  of  degenera- 
tion, in  which  the  membrane  becomes  thick,  soft,  and  villous,  not 
unlike  a piece  of  coarse  velvet.  The  change  is  evidently  in  the 
organization  of  the  membrane,  which  is  entirely  destroyed.  The 
surface  is  red  or  brown,  and  no  trace  of  the  original  structure  is 
left. 

This  is  one  of  the  most  unmanageable  forms  of  diseased  joint. 
It  may  take  place  in  any  joint,  but  is  most  common  in  the  knee- 
joint,  the  hip-joint,  and  the  elbow-joint. 

It  appears  to  be  attended  with  chronic  inflammation  of  the  sy- 
novial membrane,  and  may  probably  be  the  eflfect  of  a peculiar 
form  of  that  process.  It  seems,  nevertheless,  by  its  characters  and 
tendency,  to  arrange  itself  rather  with  the  class  of  organic  changes. 

Its  approach  is  generally  slow  but  steady,  and  it  is  attended  with 
deep-seated  pain  in  the  joint,  aggravated  hy  motion.  It  gives  rise 
to  general  swelling,  often  with  the  effusion  of  some  fluid  within  the 
synovial  cavity.  The  cellular  tissue  outside  the  capsule  also  be- 
comes diseased,  swelling,  and  being  sometimes  affected  by  second- 
ary inflammation  and  the  formation  of  abscesses. 

This  disease  takes  place  principally  in  those  reputed  of  strumous 
habit ; and  its  presence  causes  hectic  fever,  wasting,  and  debility. 

§ 3.  Thecal  Inflammation. — In  the  synovial  sheaths  of  tendons, 
inflammation  produces  effects  not  dissimilar.  The  most  marked  in- 
stance of  this  process  is  observed  in  synovial  or  thecal  whitloe,  pa- 
ronychia thecalis,  in  which  inflammation  of  the  synovial  membrane, 
I have  elsewhere  shown,  from  the  anatomical  peculiarities  of  these 
sacs,  not  only  causes  death  of  the  contained  tendon,  hut,  by  passing 
to  the  periosteum,  may  induce  caries  of  the  phalanges.*  In  other 
parts  of  the  body,  these  sheaths  are  not  very  liable  to  inflame,  un- 
less in  consequence  of  external  injury.  From  this  cause  I have 
more  than  once  witnessed  severe  inflammation  terminating  in  effu- 
sion of  purulent  fluid  in  the  synovial  sheath,  between  the  tendon 
of  the  glutceus  maximus  and  the  head  of  the  trochanter.  After  in- 
cision, however,  it  terminated  favourably,  without  appearing  to  im- 
pair the  motions  of  the  tendon. 

* Observations,  Pathological  and  Practical,  on  Whitloe.  By  David  Craigie,  M.  D. 
Edinburgh  Medical  and  Surgical  Journal,  Vol.  xxix.  p.  255.  Edinburgh,  1828. 


SYNOVIAL  MEMBRANE SYNOVIAL  RHEUMATISM.  751 

§ 4.  Ganglia. — A milder  form  of  inflammation  is  occasionally  seen 
in  these  sheaths,  terminating  in  eflPusion  of  semitransparent,  viscid> 
glairy  fluid,  like  white  of  egg.  This  eflPusion  causes  an  oblong  pro- 
minent hemispheroidal  swelling,  tense,  elastic,  and  communicating 
a sense  of  fluctuation,  which  has  been  long  distinguished  by  the 
names  of  hygroma  and  ganglion,  according  to  the  degree  in  which 
it  takes  place.  As  I restrict  the  former  appellation  to  the  serous 
cyst,  there  is  no  occasion  for  using  two  names  to  varieties  of  an 
affection  the  same  in  anatomical  characters.  Ganglion  is  subcu- 
taneous or  tendinous,  according  to  its  situation  in  the  subcutane- 
ous or  tendinous  synovial  sacs. 

§ 5.  Arthragra. — During  gout  the  synovial  sacs,  both  articular  and 
tendinous,  are  the  seat  of  an  inflammatory  process  which  terminates 
in  the  secretion  of  synovial  fluid  loaded  with  urate  of  soda. 

§ 6.  The  Synovial  Membranes  in  Rheumatism. — Though  rheuma- 
tism, as  affecting  the  aponeurotic  sheaths  and  membranes,  has  already 
been  under  consideration,  it  does  not,  however,  confine  its  action  to 
these  tissues.  From  them  it  may  either  spread  by  contiguity,  as  al- 
ready explained,  to  the  articular  capsules  and  the  synovial  mem- 
branes, or  it  may  affect  the  latter  tissues  at  once.  It  is  then  usually 
denominated  articular  rheumatism.  This  takes  place  both  in  the 
acute,  in  the  subacute,  and  in  the  chronic  forms  of  the  disease.  In 
the  two  latter,  however,  rheumatic  action  produces  eflfects  of  a serious 
and  unmanageable  character. 

Tlie  mode  of  the  approach  of  this  affection  is  in  general  the  fol- 
lowing. 

Sometimes  after  a slight  attack  of  fascial  rheumatism,  in  the  loins, 
the  back  of  the  neck,  or  one  or  more  of  the  joints,  sometimes  with- 
; out  this  preliminary  circumstance,  one  joint  is  attacked  with  a feel- 
I ing  of  stiffness,  fulness,  as  if  there  were  something  within  it,  and  dull 
obtuse  uneasiness.  These  sensations  are  relieved  while  the  joint  is 
; in  motion,  but  become  worse  when  it  is  at  rest ; and,  always  after 
resting,  the  sense  of  fulness  and  stiffness  is  aggravated,  until  it 
i amounts  to  difficult  mobility  of  the  joint. 

Swelling  does  not  appear  at  first,  but  always  comes  on  after 
I some  time.  The  joint  is  then  enlarged,  elastic,  full,  and  rounded; 

1 the  articular  angles  being  lost  in  the  swelling ; and  when  examined 
1 it  is  manifest  that  a fluid  is  contained  within  the  synovial  raem- 
I brane. 

' At  the  same  time,  it  must  be  observed,  that  in  ' articular  rheuma- 
i tism,  the  seat  of  swelling  may  be  twofold.  It  may  affect  the  peri- 


752 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


artliric  or  extra-capsular  cellular  tissue,  which  is  infiltrated  with 
sero-albuminous  fluid ; or  it  may  cause  effusion  within  the  capsule 
and  synovial  membrane.  The  former  is  the  most  favourable  and 
least  injurious.  The  latter,  if  chronic,  is  always  a troublesome  and 
sometimes  a hurtful  lesion. 

As  the  disease  proceeds,  the  stiffness  and  swelling  increase,  im- 
peding greatly  the  mobility  of  the  joint ; preventing  it  either  from 
being  fully  extended  or  easily  inflected.  Pain  is  also  superadded, 
especially  when  the  joint  is  moved ; and  if  the  joint  be  one  used 
in  supporting  the  person,  as  the  knee-joint,  the  individual  can  no 
longer  support  himself  without  pain. 

Pain,  however,  is  not  the  worst  symptom  of  this  disorder.  Stiff- 
ness, swelling,  immovableness,  and  consequent  lameness,  are  the 
usual  results. 

This  disease  may  affect  any  joint;  but  it  is  most  commonly  seen 
in  the  elbow-joints,  the  knee-joints,  the  wrists,  and  the  articula- 
tions of  the  fingers. 

The  pulse  is  not  accelerated,  nor  are  there  always  indications  of 
fever.  After  some  time,  however,  the  urine  evinces  alkaline  pro- 
perties, and  may  deposit  or  contain  ammoniaco-magiiesian  phosphate. 

As  stiffness  and  swelling  increase,  there  is  felt  on  moving  the 
joint  a grating  sensation,  and  a rough  grating  sound  may  be  heard, 
as  if  two  rough  surfaces  were  moving  on  each  other.  In  this  con- 
dition the  disease  may  continue  for  months  and  even  years. 

Death  does  not  often  take  place  in  the  early  stage,  or  in  the 
course  of  this  disease.  In  one  case,  nevertheless,  a female  who  pre- 
sented symptoms  of  it  in  one  knee-joint,  which  had  been  lasting  for 
many  weeks,  if  not  two  months  or  more,  was  attacked  with  symp- 
toms of  delirium  tremens  and  died.  The  affected  knee-joint,  which 
was  semibent,  was  examined,  and  the  synovial  membrane  was  found 
of  a bright  scarlet-red  colour,  with  numerous  blood-vessels,  a 
little  roughened  with  deposits  of  blood  and  lymph,  thickened,  and 
at  one  part  it  appeared  to  be  wearing  away  by  a species  of  absorp- 
tion. This,  however,  was  not  ulceration. 

The  state  of  the  articular  cavity  and  surfaces  in  cases  of  long 
duration,  is  the  following. 

At  first  when  the  joint  is  stiff  and  slightly  swelled,  sero-albu- 
minous fluid  is  moderately  effused.  Afterwards,  as  the  joint  is 
moved,  it  is  effused  more  copiously.  This  fluid  contains  much  urate 
of  soda,  which  is  separated  and  coats  the  membrane.  According 
to  some  it  also  contains  lime,  which  is  deposited  as  a carbonate  on 


SYNOVIAL  MEMBRANE — SYNOVIAL  RHEUMATISM. 


753 


the  membrane.  But  whatever  be  the  matter  which  it  contains,  the 
lymph  so  deposited  renders  the  surface  of  the  membrane  rough ; 
limits  and  circumscribes  the  mobility  of  the  joint ; and,  in  conse- 
quence of  the  motion  to  which  it  is  subjected,  it  becomes  hard  and 
polished  like  porcelain  or  ground  ivory ; and  in  this  state  forms  a 
sort  of  imperfect  substitute  for  the  synovial  membrane. 

Some  have  asserted  that  in  this  disease  the  synovial  membrane 
is  removed  by  absorption  and  ulceration,  and  the  cartilages  are  ul- 
cerated. This  may  occur  in  extreme  cases.  But  it  is  not  neces- 
sary to  the  disease  or  its  effects  ; and  the  most  common  result  is  li- 
mited mobility  of  the  joint  with  the  ehurneoid  deposit  or  degenera- 
tion. It  is  for  this  reason  that  the  joint  so  incrusted  has  been  said 
by  foreign  authors  to  be  affected  with  usure  or  friction  wearing. 

The  margins  of  the  articular  surfaces,  at  the  attachment  of  the 
membranes,  present  deposits  of  earthy  matter  irregularly  nodulated, 
or  tuberculated,  which  are  usually  termed  exostoses.  They  are  com- 
monly swellings  consisting  of  phosphate  and  carbonate  of  lime. 
Occasionally  the  periosteum,  near  the  articular  extremities  in  this 
disease  becomes  thickened  and  penetrated  with  the  same  material. 

On  the  tendency  of  this  form  of  rheumatism  to  affect  internal 
organs,  and  thereby  to  influence  the  duration  of  life,  different  opi- 
nions are  entertained  by  different  authors.  In  some  instances,  in- 
dividuals have  lived  long  with  it ; in  other  instances  it  has  suddenly 
proved  fatal  by  affecting  the  brain.  In  all  instances  it  impairs 
health,  and  is  an  indication  of  feeble  digestion,  imperfect  assimila- 
tion, and  an  unsound  state  of  the  circulating  fluid. 

The  nature  of  this  malady  is  not  well  known.  Some  call  it  arti- 
cular, capsular,  and  synovial  rheumatism  ; others  refer  it  to  the  head 
of  gout ; others  again  term  it  rheumatic  gout.  In  extreme  cases, 
it  has  been  known  to  produce  ankylosis  of  all  the  joints  ; and  in  the 
Museum  of  the  College  of  Surgeons  of  Dublin  is  preserved  the 
skeleton  of  a person,  who  was  in  this  manner  transformed  into  an 
inflexible  body. 

On  the  circumstances  acting  as  causes  of  this  disease,  the  opin- 
ions and  testimony  of  physicians  are  not  less  discordant  than  on  its 
nature.  By  some  it  is  represented  as  taking  place  chiefly  in  those 
in  whom  the  brain  is  overworked,  and  who  are  much  exposed  to 
causes  of  mental  anxiety.  This  may  be  the  fact  in  a certain  class  of 
cases.  But  the  disease  is  observed  in  those,  in  whom  the  brain  is  little 
or  not  at  all  subjected  to  exertion  ; and  conversely  it  does  not  take 

3 B 


754 


GENERAL  AND  PATHOLOGICAL  ANATOMY, 


place  in  all  persons,  in  whom  the  brain  is  much  exerted,  or  in  pro- 
portion to  that  exertion.  It  is  observed  as  much  in  the  temperate 
and  regular  as  in  those  of  opposite  habits  ; indeed  it  almost  never 
appears  in  persons  who  live  freely.  It  is  greatly  more  common  in 
females  than  in  males  ; and  at  Buxton  and  Bath  especially,  to  which 
patients  affected  with  it  resort,  the  proportion  of  females  to  males 
varies  from  5 to  1 to  5 to  2.  On  the  other  hand,  however,  the 
disease  is  generally  more  severe  and  obstinate  in  males  than  in  fe- 
males. It  seems  to  affect  the  labouring  classes  and  those  engaged 
in  corporeal  exertion  rather  in  a greater  degree  than  the  sedentary. 

This  disease,  when  affecting  the  joints  of  the  hands  and  fingers,  is 
liable  to  produce  not  only  ankylosis  of  the  joints,  but  great  deformity. 
The  ends  of  the  bones  are  enlarged,  and  irregularly  tuberculated 
and  knotty.  Some  of  the  phalanges  are  bent  forcibly  and  immovably 
into  the  palm  of  the  hand.  Others  stand  out  equally  immovably, 
and  do  not  admit  of  inflection.  Others  are  twisted  and  contorted  ; 
so  that  the  hand  and  fingers  are  of  little  use.  The  whole  hand  then 
not  unfrequently  is  so  deformed  as  to  resemble  the  root  of  the 
parsnip.  This  is  the  disease  described  by  Heberden,  and  after- 
wards by  Haygarth,  under  the  name  of  Nodosity  of  the  joints. 

§ 7.  Purulent  collections  within  the  synovial  membranes.  Arthropy- 
ema  after  phlebitis. — Though  purulent  matter  maybe  collected  with- 
in any  of  the  synovial  membranes,  in  consequence  of  common  in- 
flammation of  these  membranes,  the  species  of  suppuration  or  puru- 
lent collection  to  which  I here  advert,  is  peculiar  in  taking  place 
after  inflammation  of  the  inner  coat  of  a vein  or  veins.  I have 
already  shown  that,  though  venous  inflammation  often  proves  im- 
mediately fatal,  yet  instances  occur  in  which  the  mere  venous  in- 
flammation does  hot  terminate  in  death.  In  this  class  of  cases 
other  processes  take  place  which  must  be  regarded  as  the  conse- 
quences of  venous  inflammation.  To  several  of  these,  as  purulent 
collections  within  the  serous  membranes  and  extensive  suppurations 
in  the  cellular  and  adipose  tissue,  I have  already  adverted.  Be- 
sides these,  however,  purulent  matter  is  liable  to  be  formed  within 
the  synovial  membrane  of  a joint,  and  to  be  followed  by  all  the  de- 
structive consequences  attending  suppuration  within  such  a cavity. 

This  lesion  has  been  supposed  to  be  confined  to  females  with  ut^ 
r'mQ  phlebitis ; and  in  them  it  is  perhaps  more  frequent  than  in  others. 


veins,  succeeding  to  the  operation  of  venesection ; and  give  rise  to 

3 


SYNOVIAL  MEMBRANE — PHLEBITIC  ARTHROPYEMA. 


755 


all  the  exquisite  effects  of  this  destroying  process.  In  a patient  under 
my  care,  in  whom  this  accident  was  followed  by  secondary  effects,  the 
right  shoulder -joint  first  and  the  knee-joint  afterwards,  became  affect- 
ed with  pain,  heat,  swelling,  and  finally,  indications  of  the  presence 
of  fluid.  The  shoulder-joint  got  better,  under  the  use  of  various 
means.  But  the  knee  continued  swelled,  immovable,  with  much  pain, 
and  giving  indications  of  matter  in  its  interior.  Death  took  place 
soon  after.  The  interior  of  the  synovial  membrane  of  the  knee- 
joint  was  filled  with  purulent  matter  and  coagulable  lymph,  the 
latter  adhering  to  the  membrane  in  masses,  and  connecting  the 
opposing  and  corresponding  parts  of  the  membrane.  The  purulent 
matter  was  thick,  opaque,  yellow  well  formed  matter.  After  re- 
moving most  of  it,  the  synovial  membrane  was  brought  into  view, 
much  reddened  and  vascular,  especially  at  the  marginal  connections 
to  the  bones  and  enclosing  capsule,  where  also  it  was  thickened. 
Over  the  head  of  the  tibia  and  the  corresponding  parts  of  the  fe- 
moral condyles,  it  had  begun  to  be  destroyed  by  ulceration ; and  in 
several  points  the  cartilage  was  exposed.  At  the  attached  margins 
also  were  irregular  tubercular  bony  masses ; but  it  was  doubtful 
whether  these  were  the  effects  of  the  recent  disease  or  of  some  pre- 
vious orgasm. 

It  has  been  maintained  by  some,  that  these  purulent  collections 
within  the  joints  after  venous  inflammation  are  the  results  of  the 
transport  or  conveyance  of  purulent  matter  by  the  veins  into  the 
interior  of  the  joint.  Such  they  may  be  in  certain  cases.  But  iu 
the  present  instance,  and  in  others  of  the  same  kind,  which  I have 
observed,  tbe  collection  was  preceded  and  followed  by  all  tbe  usual 
symptoms  and  effects  of  inflammation ; and  I regard  the  lesion  as  an 
instance  of  inflammation  affecting  the  synovial  membrane  of  the 
knee-joint,  in  consequence  of  previous  inflammation  of  a venous 
trunk. 

§ 8.  Hemorrhage  of  the  synovial  membranes  is  not  very  common, 
but  has  nevertheless  been  observed.  M.  Pitet,  in  particular,  saw 
in  the  knee-joint  a collection  of  blood,  which  he  thinks  was  exhaled 
from  the  articular  synovial  membrane.*  When  this  effusion  does 
take  place,  it  is  an  effect  of  previous  injection  of  the  capillaries  of 
the  sac.  I have  often  thought  that  some  of  the  bloody  abscesses 
met  with  occasionally  in  the  cellular  tissue  and  in  the  neighbour- 
hood of  tendons,  depended  on  synovial  sacs  in  which  hemorrhage 
had  followed  chronic  inflammation.  This  probably  is  the  origin  of 

* Bulletin  de  la  Societe  de  Med.  p.  222. 


756 


GENERAL  AND  PATHOLOGICAL  ANATOMT. 


the  17th  case  of  Palletta,  in  which  a bloody  tumour,  containing 
pure  blood,  was  found  in  the  left  ham.*  The  incision  of  these  tu- 
mours is  always  followed  by  extensive  and  malignant,  often  fatal 
inflammation  of  the  interior  surface  of  the  cyst. 

§ 9.  Tyroma. — Synovial  membrane  is  said  to  be  liable  to  tuber- 
cular deposition.  No  doubt  can  be  entertained  of  the  frequency 
of  albuminous  deposits  ; and  I believe  tubercles  have  been  seen  in 
the  coxo-femoral  synovial  membrane  in  disease  of  that  joint.  This, 
however,  I have  not  had  an  opportunity  of  verifying. 

§ 10.  Cartilage. — In  some  instances,  cartilaginous  bodies  are  ob- 
served to  adhere  by  a narrow  peduncle  to  the  free  surface  of  the 
synovial  membranes.  This,  though  most  frequently  observed  in 
the  femoro-tibial  articulation,  is  certainly  not  peculiar  to  it.  These 
bodies  may  be  either  generated  by  morbid  action  of  the  synovial 
tissue,  or  may  be  portions  of  cartilage  or  fibro- cartilage  broken 
accidentally  from  some  part  of  the  articular  apparatus,  and  suffered 
again  to  contract  adhesion  to  the  synovial  membrane  by  the  inflam- 
mation which  their  presence  induces. 

§ 11.  Hematoid fungus,  or  cerebriform  degeneration,  is  a disease 
which  often  originates  in  the  Interior  of  joints.  The  circumstances 
under  which  this  begins  render  it  difficult  to  ascertain  the  tex- 
ture primarily  affected.  It  is,  nevertheless,  most  probable  that 
it  is  chiefly  the  synovial  membrane  in  which  this  tumour  commences. 
In  the  cases  of  the  disease  which  have  been  inspected  before  much 
destruction  has  taken  place,  the  articular  extremities  of  one  or  both 
bones  have  presented  large  fungous  spongy  masses  of  matter  like 
brain,  and  well  supplied  with  blood-vessels ; and  it  has  been  im- 
practicable to  recognize  any  trace  of  synovial  membrane  or  carti- 
lage. The  analogy  between  the  serous  and  synovial  sacs  in  this 
respect  is  obvious. 

The  degeneration  may  take  place  in  any  joint,  but  affects  com- 
monly the  shoulder-joint,  the  hip-joint,  and  the  knee-joint. 

§ 12.  Scirrho-carcinoma  appears  not  to  originate  in  this  tissue, 
but  certainly  affects  it  from  collateral  tissues.  Some  authors  have, 
indeed,  with  singular  vagueness,  spoken  of  certain  forms  of  white 
swelling  or  fungus  articidi,  as  being  a sort  of  cancerous  disease. 
This,  however,  is  only  one  of  many  errors  which  originate  in  the 
practice  of  applying  a vague  general  ej)ithet  to  many  different 
morbid  states. 

* Exercilaiiones  Patliologicee,  p.  207. 


BOOK  V. 


CHAPTER  I. 

GLANDULAR  TISSUE.  THE  GLANDS.  THE  GLANDULAR  SYSTEM. 

GLANDULE.  DRUSEN. 

Section  I. 

GENERAL  CHARACTER  OE  GLANDS. 

A gland  may  be  defined  to  be  an  organ,  or  organized  texture, 
consisting  of  blood-vessels  and  nerves  ; tbe  blood-vessels  very  nume- 
rous, arranged  in  a particular  manner,  and  communicating  with  a 
series  of  sacculated  cavities,  vesicles,  or  hollow  tubes ; intended  for 
the  purpose  of  receiving  or  preparing  from  the  blood,  or  secreting, 
a substance  of  peculiar  properties,  either  to  be  applied  to  some  pur- 
pose within  or  without  the  economy,  or  to  be  conveyed  entirely  out 
of  the  system. 

According  to  the  terms  of  this  definition,  the  denomination  gland 
comprehends  only  the  secreting  or  conglomerate  glands,  or  those 
organs  which  are  known  to  secrete  some  substance,  generally  liquid, 
and  to  deposit  the  same  in  cavities  communicating  with  an  emissary 
duct  or  ducts. 

These  are  by  various  authors  denominated  perfect  glands. 

By  imperfect  glands  the  same  authors  understand  organs  with 
apparent  glandular  structure,  but  without  visible  secreting  appa- 
ratus, secreted  product,  or  excretory  duct,  as  the  thymus  gland  in  the 
infant,  the  thyroid  gland,  and  according  to  some  the  spleen.  It  is 
evident  that  the  term  imperfect  gland  is  equivalent  to  thatof  no  gland. 

Some  anatomists,  guided  by  physiological  and  in  a certain  sense 
transcendental  considerations,  have  proposed  to  add  to  the  order  of 
glands,  the  lungs,  because  they  separate  or  secrete  carbonaceous 
matter  from  the  blood ; and  many  have  in  this  manner  classed  the 
lungs  with  the  liver  and  the  kidneys  under  the  head  of  emunctory 
or  excreting  organs. 


758 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Others  again  have  proposed  to  refer  to  the  order  of  glands  the 
ovaries  of  the  female,  because  they  are  analogous  to  the  testes  of 
the  male  ; and  they  have  regarded  the  ova  as  secreted  or  excreted 
products  ; and  the  Fallopian  tubes  as  excretory  ducts.  This  view 
rests,  it  must  be  admitted,  upon  some  analogy  both  anatomical  and 
physiological.  But  it  is  enough  to  mention  it  here  ; nor  do  1 think 
it  proper,  in  a work  of  this  kind,  to  introduce  views  which  may  re- 
quire further  confirmation. 

Under  the  glandular  system  I include  the  following  organs  ; the 
lacrymal  gland ; the  salivary  glands,  viz.  the  parotid,  the  sublin- 
gual, and  the  sabmaxillary  glands ; the  liver  and  the  pancreas ; the 
kidneys ; the  testes,  the  prostate  gland,  and  Cowper’s  glands  in  the 
mate ; and  the  mammae  in  the  female ; the  sebaceous  follicles  of 
the  skin,  and  the  muciparous  follicles  of  the  mucous  membranes. 

On  no  subject  in  general  anatomy  has  information  been  so  void 
of  precision  and  accuracy  as  on  the  structure  of  the  glands.  By 
several  anatomists  the  structure  has  been  believed  to  be  the  same 
in  all ; and  consequently,  what  was  supposed  to  be  ascertained  as 
to  one  has  been  applied  indiscriminately  to  all.  Little,  indeed,  was 
ascertained ; and  few  accurate  facts  were  recorded.  Sylvius  and 
Steno,  Glisson*  and  Wharton, t were  the  principal  inquirers  previous 
to  the  time  of  Malpighi ; and  both  the  two  latter  did  communicate 
some  information.  These  anatomical  results,  however,  were  much 
influenced  by  various  physiological  notions  on  the  nature  of  secre- 
tion ; and  as  the  latter  were  often  erroneous,  the  former  were  rarely 
in  all  points  correct. 

Malpighi,  in  1661,  taught  that  all  glands  consisted  of  an  aggre- 
gation or  collection  of  minute  saccular  organs,  {utriculi),  in  which 
the  blood-vessels  were  distributed,  and  which  saccular  organs  he 
denominated  sometimes  small  glands,  {glandules),  sometimes  acini. 
Acini  in  the  liver  he  represents  to  consist  of  simple  glandules  col- 
lected in  clusters,  which  glandules  are  hollow  membranous  cavities. 
These  acini  are  in  shape  hexagonal  or  polyhedral.  The  glandular 
bodies  in  the  kidneys,  on  the  other  hand,  are  round  or  spherical  like 
the  ova  of  fishes ; but  these  glandules  are  in  like  manner  hollow.J 

* Francisci  Glissonii  Anatomia  Hepatis.  12mo.  Londini,  1654. 

-f-  Thomas  Wharton  Adenogi-aphia,  seu  Glandulamm  totius  Corporis  Descriptio.  8vo. 
Londini,  1656. 

+ Marcelli  Malpighii  Exercitationes  Anatomicae  de  Structura  Viscerum  ; nomina- 
tim,  Hepatis,  Cerebri  Corticis,  Renum,  Lienis.  cum  Dissertatione  de  Polypo  Cordis  ct 
Epistolis  Duabus  cle  Puimonibus.  apud  Opera  Omnia.  Tomum  Secundum.  Folio, 
Londini,  1687. 


GLANDULAR  TISSUE. 


759 


Ruysch  was  confident  that  the  final  structure  of  all  glandular 
organs  consists  in  fasciculi  of  blood-vessels  ramified  to  an  infi- 
nite degree  of  minuteness.  He  admitted,  indeed,  in  1722,  when 
eighty-five  years  of  age,  that  sixty  years  previously  he  had  taught 
the  existence  of  acini  or  little  glands  with  membranous  cavities,  ac- 
cording to  the  received  opinion.  Afterwards,  how'ever,  by  much 
observation  in  injection,  he  became  convinced,  that  these  acini  are 
composed  of  blood-vessels  only,  and  not  of  little  hollow  membranes 
with  an  outlet* * * §  He  allows,  nevertheless,  that  the  liver  contains 
acini  or  acinuli ; but  repeats  bis  doctrine,  that  these  are  not  small 
glands  or  hollow  sacs,  but  very  delicate  pulpy  vessels.! 

Ferrein,  in  the  middle  of  the  18  th  century,  called  in  question 
both  of  these  doctrines.  He  maintained  that  the  liver  and  the  cor- 
tical part  of  the  kidney  consist  neither  of  blood-vessels  nor  of  small 
glands,  but  of  a peculiar  substance  formed  by  a wonderful  collection 
of  white  cylindrical  tubes  variously  folded,  which,  he  contended,  he 
demonstrated  manifestly  in  the  kidneys, — which  he  had  seen  in  the 
liver  and  renal  capsules,  and  which  he  believed  he  could  make 
known  in  other  glandular  organs.^ 

Plaller  has  collected  under  the  several  heads  of  the  pancreas,  the 
liver,  the  kidneys,  the  testes,  the  mamma,  and  other  glands,  the  re- 
sults of  the  inquiries  of  different  anatomists  to  his  own  time  (1777.) 
In  the  liver  he  admits  the  existence  of  acini,  and  he  adopts  the  view 
of  Malpighi,  representing  them  to  consist  of  simple  hollow  glan- 
dules collected  in  clusters  ; that  these  acini  are  hexagonal ; and  are 
not  an  element  but  a mass  of  elements ; or,  in  short,  that  they  are 
the  lobules  of  the  liver  enclosed  in  cellular  tissue.  § 

Each  kidney  he  represents  to  consist  of  several  little  kidneys  (re«- 
culus') ; each  of  which,  again,  consists  of  cortical  or  vascular  and 
medullary  or  striated  matter.  || 

* Opusculum  Anatomicum  de  FabricaGlandularum  in  Corpore  Humano,  Continens 
Binas  Epistolas,  Quarum  Prior  est  H.  Boerhaave,  super  hac  re,  ad  Friedericum  Ruys- 
chium;  Altera  F.  Ruyschii  ad  H.  Boerhaave,  Qua  priori  respondetur.  Amstelsedami, 
1721  et  1722.  Apud  Ruyschii  Opera  Omnia,  Tomum  iv.  p.  71-  Amstelsedami,  1733, 4to 

-f-  “ Acini  ibi  (in  hepate)  manifesti  semper  sunt  agniti  a me  ; sed  ego  tan  turn  dixi 
quod  non  sunt  folliculi  membranacei  cavi  cum  emissario,  sed  quod  sint  vascula  pulposa 
tenerrima.  Epistola,  p.  75. 

J Observations  sm-  la  Structure  des  Glandes,  et  part,  des  Reins,  et  du  Foi.  Me- 
moirea  de  PAcademie  Royale  des  Sciences.  Paris,  a.  1749.  Hist.  p.  92.  Mem.  p 
489. 

§ Elementa  Pbysiologiae,  Lib.  xxvi.  Sect.  I.  § xxvi.  xxvii. 

!|  Elementa,  Lib.  xxvi.  Sect.  I.  § vii.  and  viii. 


760 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


In  1788  Schumlanskl  published  his  dissertation  on  the  structure 
of  the  kidney,  and  thereby  directed  attention  to  the  arrangement  both 
of  the  cortical  or  vascular  part  of  these  glands,  and  to  that  of  the 
tubuli  Belliniani  or  excreting  ducts.  He  did  not,  however,  eluci- 
date much  the  intimate  structure  of  the  organ.* 

The  facts  and  statements  given  by  Haller  were  very  generally 
repeated  by  Soemmering  and  other  anatomists.  Bichat  alone  re- 
jected many  without  substituting  others  in  their  place,  and  main- 
tained that  whatever  could  not  be  sensibly  demonstrated  was  to  be 
regarded  as  Tincertain  and  undeserving  attention. 

Various  inquirers  continued  to  investigate  this  department  of 
anatomy,  with  different  degrees  of  success,  during  the  first  third  of 
the  19th  century.  In  1818  Eysenhardt  published  his  dissertation 
on  the  structure  of  the  kidneys,  in  which,  with  various  errors,  he 
gave  correct  views  of  the  corpora  Malpighiaria.\  In  1819  Doel- 
linger,  in  a dissertation  on  secretion,  adduced  several  curious  facts 
regarding  the  arrangement  of  arteries  in  several  glands.:}:  These 

were  followed  by  the  essays  of  Rathke  and  Huschke  on  the  struc- 
ture of  the  kidneys,  the  observations  of  Weber  on  the  salivary 
glands,  and  those  of  Baer  on  the  liver.  The  researches  of  all 
these  inquirers,  however,  though  most  valuable,  have  been  in  a 
great  degree  eclipsed  by  the  elaborate  commentary  on  the  glands, 
published  in  1830,  by  John  Muller,  first  of  Bonn  and  afterwards 
of  Berlin,  who  has,  with  great  skill  and  much  personal  research,  elu- 
cidated the  structure  of  all  the  glands  in  a systematic  manner,  com- 
bining the  researches  of  all  his  predecessors.  Since  the  date  of  the 
monograph  of  Muller,  various  facts  of  considerable  value,  chiefly 
microscopical,  have  been  added  by  subsequent  observers. 

In  the  following  account  I shall  study  to  combine  the  results  ob- 
tained by  all  these  inquirers. 

Muller  distinguishes  all  the  glands  of  the  animal  body  into  nine 
orders,  in  the  following  manner. — 

I.  Glands  of  the  first  and  most  simple  order. 

1.  Crypts  or  cells,  a.  Solitary  crypts  of  the  mucous  mem- 
branes. b.  Aggregated,  agminated,  or  agglutinated  crypts, 
as  the  glands  of  Peyer  in  the  intestines. 

^ F.  Schumlansky  Dissertatio  de  Stnictura  Renum.  8vo.  Argentorati,  1788. 

d*  Carol.  Guilelm.  Eysenhardt  de  structura  Renum,  Observation es  microscopicae 
cum  Tab.  aen.  4 Maj.  BeroMni,  1818. 

+ Wa.s  ist  Absonderung  und  wie  gescbieht  sie.  Wurzburg,  1819. 


GLANDULAR  TISSUE. 


761 


2.  Follicles  or  pedunculated  vesicles,  a.  Solitary,  as  those 
of  the  skin.  b.  Associated,  as  the  aggregated  follicles  in  the 
auricular  glands  of  amphibious  animals. 

3.  Elongated  bladders,  (utricui.i  elongati,)  sacs,  or  c^ca. 
This  glandular  apparatus  consists  in  the  eversion  of  a simple 
membrane,  which  is  prolonged  without  contraction  or  terminal 
enlargement. 

These  are  either,  a.  simple  intestinula,  occurring  in  the  mucous 
membranes,  or  b.  aggregated  intestinula^  like  the  Meibomian 
glands  of  mammalia,  and  the  glands  of  the  stomach  of  birds. 

4.  Tubuli  or  BLIND  sacs;  (c^ca.) 

These  are  either,  a.  solitary  tubules,  as  the  secretory  organs 
of  several  insects  ; or  b.  Aggregated  tubules,  as  the  glands 
of  the  oviducts  of  the  ray  and  shark,  consisting  of  parallel  tu- 
buli, the  oesophageal  glands  in  certain  birds,  and  the  pyloric 
appendages  of  some  fishes. 

II.  Glands  of  the  second  order.  Compound  Crypts.  Fol- 

licles. Intestinules.  Compound  tubules. 

1.  Compound  crypts,  or  compound  cells,  in  which  several 
crypts  are  united. 

a.  Berry-like  crypts,  as  in  the  anal  glands  of  the  hyena. 

b.  Bladders  with  cells,  (crypto  loculat^,)  as  in  the  prae- 
putial  glands  of  the  dormouse. 

c.  Tubules  with  internal  cells,  as  the  salivary  glands  of  some 
insects. 

d.  Flower-like  crypts,  or  crypts  united  as  flowers,  as  in  the 
testicles  of  insects. 

2.  Compound  follicles,  or  compound  pedunculated  vesi- 
cles. Follicles  united  in  various  modes. 

3.  Compound  c^ca.  Intestinal  c<Eca  united  in  various  modes. 

4.  Tubuli  compositi.  Tubules  or  hollow  cylinders  united  in 
various  modes. 

III.  Glands  of  the  third  order  ; compound  cells,  follicles, 
Intestinules.  Compound  Tubules  united  so  as  to  form  one 
glandular  sac. 

IV.  Glands  of  the  fourth  order.  Glands  composed  of 
SPONGY  CELLULAR  TEXTURE,  variously  arranged  ; sometimes  in 


762 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  form  of  tubules,  sometimes  of  cells,  sometimes  of  glandular 
cells  inclosed  within  membranous  partitions  {septa.) 

V.  Glands  of  the  fifth  order.  Lobulated  glands  com- 

posed OF  aggregations  of  small  intestinal  c^ca. 

1.  A gland  composed  of  clusters  of  small  intestinal  caeca  arranged 
in  lobules,  as  the  pancreas  of  the  tunny. 

2.  A gland  composed  of  blind  branching  intestinula.,  arranged  like 
leaves  in  lobules ; for  instance,  the  prostatic  glands  and  Cowper’s 
glands  in  the  hedgehog. 

3.  A gland  composed  of  branched  intestinula  caeca  irregularly  ar- 
ranged. 

VI.  Glands  of  the  sixth  order.  Branched  excretory 

DUCTS  INCLOSED  FROM  THEIR  ORIGIN  TO  THEIR  TERMINATION  BY 
ELEMENTARY  PARTICLES. 

This  arrangement,  which  resembles  efflorescence,  is  not  terminal, 
but  is  similar  to  the  protracted  efflorescence  of  botanical  terminology. 
Of  this  examples  are  found  in  the  liver  of  the  crustacea,  the  lacry- 
mal  gland  of  the  tortoise,  and  the  lacryraal  gland  of  birds. 

VII.  Glands  of  the  seventh  order.  Compound  ramifica- 
tion IN  A LOBULATED  GLAND,  WITH  TRUNKS  OF  EXCRETORY 
DUCTS  CONTINUOUS  AND  ENTIRE  AMONG  LATERAL  BRANCHES 
AND  VESICULAR  ENDS  OF  ULTIMATE  DUCTS. 

The  trunk  of  the  excretory  duct,  entire  and  continuous,  is  not 
divided  into  branches,  but  sends  out  laterally  small  branches,  which 
are  also  continued  entire  and  without  interruption  by  lateral  rami- 
fication. The  result  of  this  arrangement  is  great,  small,  and  very 
small  lobules ; because  each  trunk  with  lateral  branches  makes  a 
large  lobe ; branches  with  lateral  shoots  make  small  lobes  of  the 
second  order ; and  from  the  twigs,  and  their  attached  portions  the 
smallest  lobules  arise.  This  origin  of  the  lobules  is  shown  from 
the  history  of  the  development  of  the  embryo. 

To  this  mode  of  arrangement  belong  the  salivary  glands,  the 
pancreas,  the  ynammoi,  and  the  lacryraal  gland  of  many  mammalia. 

VIII.  Glands  of  the  eighth  order.  Compound  ramifica- 
tions IN  GLANDS  NOT  LOBULATED  WITH  DIVISION  OF  TRUNKS 
INTO  IRREGULAR  BRANCHES,  WITH  SHORT  OR  TERMINAL  VESI- 


GLANDULAR  TISSUE. 


763 


CULAR  TWIGS,  (as  in  the  pancreas  of  birds ; and  in  the  liver  of 
the  embryo  of  birds  and  mammalia.) 

IX.  Glands  of  the  ninth  order.  Consisting  of  short 

TUBULES  AND  VESSELS,  NOT  RAMIFIED. 

The  elements  of  the  glands  in  this  order  are  tubules  long  and 

very  long ; of  equal  diameter  to  their  short  ends ; either  straight 

or  serpentine.  At  the  origin  they  are  often  furcated ; after  that 

simple  without  giving  branches.  They  appear  under  six  forms. 

1.  From  a lateral  excretory  duct  arise  bundles  of  tubules,  as  in 
the  kidneys  of  many  fishes,  and  batrachoid  animals,  and  in  the 
testes  of  fishes.  The  tubules  proceed  either  parallel  towards  the 
opposite  margin,  as  in  the  kidneys  of  the  petromyzon  and  frogs, 
and  the  testes  of  fishes ; or  they  wind  tortuous  and  serpentine,  as 
in  the  kidneys  of  the  ray  family  and  serpents. 

2.  Bundles  of  parallel  tubules  everywhere  issue  from  branching 
excretory  ducts.  Such  are  the  kidneys  of  the  crocodile  and  tor- 
toise. 

3.  An  excretory  duct  divided  into  very  long  uniform  serpentine 
vessels;  as  the  seminiferous  canals  of  the  higher  animals,  and 
the  prostate  glands  of  the  hedgehog. 

4.  Tubules  forked  and  fasciculated  like  rays  or  wheel-spokes,  pro- 
ceeding from  an  excretory  duct ; as  in  the  testes  of  frogs  and 
cuttle-fish. 

5.  Very  long  vessels ; pinnatifid  at  apex ; closed;  rising  in  bundles 
from  a branched  excretory  duct ; as  in  the  kidneys  of  birds. 

6.  Very  long  vessels  rising  in  bundles,  at  first  bifurcated,  then  pur- 
suing a serpentine  course,  without  branches.  The  kidneys  of 
the  mammalia  and  man.  The  proportion  between  the  ureter 
and  the  uriniferous  ducts  varies  in  three  modes. 

a.  The  ureter  is  continued  to  branches;  from, these  arise 
bundles  of  uriniferous  ducts  arranged  in  separate  lobules, 
externally  serpentine,  as  is  seen  in  the  kidneys  of  the  cetacea. 

b.  One  single  ureter  passes  into  a pelvis  and  calyces^  which 
receive  the  bundles  of  the  uriniferous  ducts.  These  bundles 
are  evolved  in  the  lobated  kidney,  externally  serpentine ; 
but  the  lobules  are  not  altogether  separated,  as  in  the  kid- 
neys of  several  mammalia. 

c.  In  the  kidneys  of  the  rest,  even  the  superficial  lobes  of  the 
kidneys  disappear. 


764 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


To  explain  this  numerous  list  of  the  different  forms  of  glandular 
structure,  it  is  necessary  first  to  premise  certain  general  facts  illus- 
trating the  essential  characters  of  glandular  organs,  and  then  to  at- 
tend to  the  following  statements,  in  which  a summary  is  given  of  the 
result  of  all  the  inquiries. 

The  simplest  idea  of  a gland  is  to  be  found  in  such  organs  as 
the  pyloric  appendages  of  fishes,  the  pancreas  of  certain  fishes,  as 
the  sturgeon,  and  the  kidneys  of  several  of  the  fishes. 

In  the  first  case,  that  of  the  pyloi’ic  appendages,  {appendices  py- 
loriecB),  which  are  well  seen  in  the  cod  and  haddock,  a great  num- 
ber of  cylindrical  canals  or  tubes  with  closed  ends  hanging  free  in 
the  abdominal  cavity,  and  with  open  ends  communicating  with  the 
bowel  are  attached  to  the  pylorus  or  duodenum.  The  number  of 
these  canals  or  tubes  varies  from  50  to  80,  150,  or  200  in  different 
genera.  They  are  membranous,  and  open,  as  already  stated,  into 
the  interior  either  of  the  pylorus  or  duodenum. 

These  bodies  are  understood  to  perform  the  function  of  secreting 
glands.  Their  inner  surface,  which  is  continuous  with  the  raucous 
surface  of  the  intestine,  is  believed  to  secrete  a fluid  necessary  to 
the  proper  performance  of  digestion  and  solution  of  the  alimentary 
mass.  Part  of  the  food  seems  to  enter  them,  and  after  being  subject- 
ed to  the  action  of  this  fluid,  to  be  returned  into  the  intestine  ; proba- 
bly allowing  other  portions  in  succession  to  undergo  the  same  action. 

This  arrangement  may  be  regarded  as  presenting  that  of  a tu- 
bular gland. 

The  pancreas  or  pancreatoid  organ  of  the  sturgeon  is  an  or- 
gan in  external  appearance  and  consistence  somewhat  different, 
but  in  internal  arrangement  similar. 

Externally  it  is  a thick  fleshy  firm  mass,  triangular,  or  pentahe- 
dral rather,  in  shape,  with  one  apex  hanging  free  into  the  abdominal 
cavity,  and  with  tbe  base  attached  to  the  duodenum.  The  colour 
of  the  pancreatoid  organ  is  greenish-black,  with  pansy  purple,  in- 
terspersed with  whitish  or  whitish-gray  spots.  Its  parietes  vary  in 
thickness,  according  to  the  size  of  the  animal,  from  half  an  inch  to 
one  inch  or  one  inch  and  a half. 

This  organ  is  attached  to  the  duodenum  near  its  pyloric  end  ; 
and  with  this  its  cavities  communicate  by  means  of  a large  oi’ifice 
placed  in  a recess  opposite  to  the  pyloric  opening.  This  orifice  is 
circular  or  slightly  elliptical,  sufficiently  large  to  admit  the  tip  of 
the  finger,  and  even  more  in  large  animals. 

4 


GLAND  ULxVR  TISSUE. 


765 


This  large  orifice  speedily  diverges  into  several  similar  orifices  ; 
and,  when  these  are  exposed  by  sections,  they  are  observed  to  ter- 
minate in  spherical  and  spheroidal  cavities,  in  which  are  similar 
orifices  leading  to  similar  cavities, — all  communicating  in  the  same 
manner  with  each  other.  The  size  and  capacity  of  these  cavities 
varies  according  to  the  size  of  the  animal.  Thus  in  a sturgeon  six 
feet  long  they  are  in  general  about  one  inch  or  more  in  diameter. 
In  smaller  animals  they  are  not  more  than  half  an  inch : and  in 
large  individuals  they  are  larger.  These  dimensions,  nevertheless, 
it  is  difficult  to  specify ; as  their  accuracy  depends  much  on  the 
shape  of  the  cavities,  which  is  not  exactly  spherical,  but  only  irre- 
gularly so. 

The  pancreatoid  organ,  therefore,  of  the  sturgeon  consists  of  a 
series  of  rounded  cavities  communicating  with  each  other,  and  with 
the  duodenum  by  one  general  large  orifice.  The  whole  of  these 
cavities  are  lined  by  a.  membrane  quite  similar  to  that  which  forms 
the  inner  lining  of  the  duodenum ; and  for  a particular  description 
of  which  I refer  to  another  work.* 

The  surface  of  this  inner  membrane  evidently  secretes  a liquid 
which  is  applied  to  the  alimentary  mass  in  a peculiar  manner. 
The  liquid  does  not  flow  by  the  outlet  into  the  duodenum.  But 
the  alimentary  mass,  after  it  has  been  received  from  the  stomach, 
is  conveyed  in  successive  portions  into  the  communicating  cells 
of  the  pancreas  ; there  the  secreted  liquid  is  effused  on  them ; and 
after  they  have  undergone  its  proper  action  they  are  expelled  ; and 
other  portions  of  the  alimentary  mass  are  introduced  in  order  that 
they  may  be  impregnated  with  pancreatic  fluid  in  like  manner. 

In  all  the  specimens  of  the  sturgeon  which  I have  examined,  I 
have  always  found  the  pancreatoid  cells  quite  filled  with  chyme  or 
alimentary  pulpy  matter,  evidently  in  a more  advanced  stage  of 
digestion,  than  that  contained  in  the  stomach  and  pyloric  end  of  the 
duodenum. 

The  arrangement  is  singular  in  this  respect,  that  the  chyme  is 
conveyed  into  an  organ  to  be  subjected  to  the  operation  of  its  se- 
creted product ; and  after  this,  is  not  conveyed  through  the  organ, 
for  which  there  is  no  provision,  but  is  withdrawn  from  its  cells, 

* On  the  Anatomical  Peculiarities  of  the  Sturgeon.  {Aciperiser  Sturio.)  By  DaUd 
Craigie,  M.  D.,  &c.,  Memoirs  of  the  Wernerian  Natural  History  Society,  Vol.  vi.  p. 
364.  Edin.  1831. 


766 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


and  urged  on  its  onward  course  through  the  rest  of  the  intestinal 
canal.  The  chyme  may  nevertheless  be  said  to  make  the  circuit 
of  the  pancreatoid  chambers. 

Notwithstanding  this  arrangement,  the  pancreatoid  organ  is  re- 
garded by  most  anatomists  as  an  example  of  a gland  ; and  except- 
ing the  circumstance  of  the  chyme  being  conveyed  to  its  interior, 
instead  of  its  secreted  product  being  conveyed  to  the  chyme,  it  may 
be  regarded  as  presenting  on  the  large  scale,  the  structure  and  in- 
ternal arrangement,  which  in  other  glands  is  so  minute  and  delicate 
as  to  elude  observation. 

In  short,  the  pancreatoid  organ  of  the  sturgeon  may  be  regard- 
ed as  an  aggregation  of  glandular  sacs  or  cells,  communicating 
with  each  other,  and  the  interior  of  which  furnishes  a liquid  secret- 
ed from  its  blood-vessels,  which  are  large  and  numerous. 

There  is,  however,  still  one  point  on  which  information  is  want- 
ing. This  is,  how  do  the  blood-vessels  terminate  and  communicate 
with  this  secreting  surface  ? On  this  point  no  accurate  information 
has  been  obtained. 

The  kidneys,  or  rather  the  urinary  organs,  of  the  sturgeon  in 
like  manner  may  be  taken  as  organs  illustrating  what  may  be  re- 
garded as  the  most  simple  form  of  glandular  structure. 

The  urinary  organs  of  the  sturgeon  consist  of  two  long  tubular 
canals,  placed  on  each  side  of  the  intestine  with  the  spiral  valve, 
and  resting  on  the  spinal  column  and  its  muscles,  to  which  they 
are  attached  by  cellular  membrane.  These  organs  resemble  neither 
the  kidneys,  nor  the  ureters,  nor  the  bladder  of  the  Mammalia  and 
Birds,  but  combine  the  characters  of  all  these.  Their  parietes  are 
thin  and  membranous,  so  as  to  seem  like  elongated  bladders  or  utri- 
culi.  Their  inner  surface,  which  is  red,  smooth,  and  mucous,  but  not 
distinctly  villous,  presents  a series  of  minute  orifices  not  larger  than 
pin  heads.  These  orifices  or  pores  correspond  partly  to  the  infun- 
dibula, partly  to  the  uriniferous  tubes  of  mammiferous  animals. 
The  lower  extremities  of  these  canals  widen ; and,  suddenly  con- 
tracting, terminate  in  one  common  outlet  or  vent,  which  opens  on 
the  surface  behind  that  of  the  intestine  at  the  anal  fin. 

These  urinary  organs,  which  in  this  manner  represent  at  once^ 
kidneys,  ureter,  and  bladder,  and  even  urethra,  are  membranous  ' 
sacculi  or  utriculi,  which  in  this  manner  act  as  glandular  surfaces, 
or  secreting  and  excreting  surfaces.  The  small  pores  are  the  out- 
lets of  the  secreting  portion ; but  around  them  the  parts  are  so 


GLANDULAR  TISSUE. 


767 


thin  and  membranous,  that  they  may  be  justly  regarded  as  the  ru- 
diraental  or  essential  portions  of  the  kidneys. 

Of  the  mode  in  which  the  blood-vessels  communicate  with  these 
pores  and  their  membranes,  nothing  is  accurately  known,  except 
that  the  vessels  ramified  to  an  infinite  degree  of  delicacy  and  mi- 
nuteness terminate  in  the  membrane. 

Thus  it  appears  that  the  most  simple  and  elementary  form  of  a 
gland  is  a hollow  cylinder  or  tube  communicating  either  directly 
with  the  surface  of  the  body,  or  indirectly  by  opening  on  a mucous 
membrane ; that  the  superior,  internal,  or  upper  end  of  this  tube 
presents  the  form  of  a closed  sac;  that  the  shut  end,  nevertheless, 
communicates  in  different  modes  with  the  vascular  system ; or 
that  branches  and  ramifications  of  the  vascular  system  terminate 
on  this  closed  end.  It  further  will  afterwards  appear,  that  the 
forms  which  this  arrangement  and  connection  with  the  vascular 
system  presents,  may  be  very  much  varied. 

Meanwhile,  it  is  necessary  to  state  here  the  general  characters 
of  every  form  of  gland. 

I.  All  glands,  however  much  they  may  depart  from  the  confor- 
mation of  secreting  vessels,  nevertheless  follow  one  common  fixed 
law  of  formation,  and  present  an  uninterrupted  series  from  the 
most  simple  unramified  follicle,  to  the  most  complicated  structure. 

II.  Between  the  secreting  organs  of  Aspondylous  animals  and 
the  glands  of  the  higher  classes  no  fixed  distinction  in  truth  exists. 
But  simple  follicles,  and  tubuliform  secreting  organs,  and  closed 
intestinula  are  repeated  not  only  in  animals  of  the  higher  classes, 
but  pass  by  an  unbroken  series  through  the  different  classes  of  ani- 
mals, gradually  into  conglomerate  glands.  Thus  the  mammcB  of 
the  Cetacea  and  Ornithorhyncus,  the  simple  salivary  glands  of 
birds,  the  prostatic  glands  of  several  mammalia,  and  the  pancreas 
of  several  fishes  are  formed  after  the  manner  of  small  cocca  or 
closed  intestinula,  as  observation  shows  regarding  the  secreting  or- 
gans of  the  CRUSTACEA  and  insects. 

III.  All  glands  with  a system  of  secreting  ducts  present  inter- 
nally a very  large  secreting  surface.  But  the  variety  of  forms  in 
which  the  secreting  surface  is  increased  within  small  space,  is  innu- 
merable. There  is  indeed  boundless  diversity  and  profuseness  ; yet 
there  are  in  all  glands  certain  common  characters.  The  variety 
in  the  testes  or  seminiferous  canals  in  insects  is  so  great,  as  to  re- 
semble the  profuseness  of  the  forms  presented  by  the  vegetable 


768 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


kingdom.  Yet  of  all  glands  it  is  a common  character,  that  from 
the  more  full  evolution  of  an  excreting  duct,  they  increase,  in  pro- 
portion as  the  canals  terminated  by  closed  ends  are  increased.  The 
hypothesis  of  Malpighi,  accordingly,  on  the  structure  of  the  glands, 
makes  a nearer  approach  to  the  truth  than  that  of  other  anato- 
mists ; and  its  correctness  is  confirmed  beyond  doubt,  in  all  the 
forms  of  glands.  Malpighi,  however,  was  little  acquainted  with 
the  elementary  forms  of  glands,  which  he  represented  in  all  cases 
to  be  follicles  and  acini. 

The  objects  which  Malpighi  considered  to  be  follicles  in  the  vis- 
cera, were  bodies  consisting  of  masses  of  much  smaller  particles, 
in  which  terminate  the  final  twigs  of  the  efferent  ducts.  Then, 
besides  follicles,  the  variety  of  forms  of  closed  sacs  in  which  the  se- 
creting canals  terminate  is  great ; for  they  are  either  utriculi,  or 
elongated  tubular-shaped  intestimda^  or  pinnatifid  and  paniculate 
canals  ending  in  closed  sacs,  or  canals  evei’ywhere  equal  in  diame- 
ter, very  long,  serpentine,  and  not  branched.  This  point,  however, 
in  which  is  placed  the  force  of  the  hypothesis  of  Malpighi,  is 
certain,  that  the  small  twigs  of  the  efferent  and  secreting  ducts  are 
closed  at  their  blind  or  shut  ends  in  the  cellular  tissue  of  the 
glands. 

This  is  the  case  with  the  mamma;  of  the  mammalia,  the  salivary 
glands  in  various  classes  of  animals,  the  pyloric  appendages,  and 
the  parenchymatous  pancreas  of  fishes,  the  biliferous  ducts  of  the 
liver,  the  tubuli  of  the  kidney,  and  the  testicles. 

IV.  Acini.,  considered  as  glandular  grains  or  hypothetical  balls 
of  blood-vessels,  from  which  secreting  vessels  are  supposed  to  pro- 
ceed, are  fictitious.  There  is  no  immediate  and  continuous  pas- 
sage of  blood-vessels  into  efferent  vessels  either  in  acini  or  any- 
where else.  The  system  of  secreting  vessels  is  peculiar,  distinct 
from  the  blood-vessels,  terminating  in  closed  extremities  in  all 
forms  of  glands. 

V.  Acini,  therefore,  are  merely  closed  ends  of  secreting  canals, 
or  a branchy  group  of  the  same  parts,  that  is  vesicles,  which  may  be 
perfectly  filled  with  mercury,  and  in  some  glands  inflated.  Truly 
solid  granules  are  seen  only  in  the  testes  of  a few  fishes,  the  testes 
of  which,  without  excretory  duct,  send  granules  into  the  abdominal 
cavity,  from  which  they  are  conveyed  by  a proper  orifice  in  the  ab- 
doun  n. 

VI.  The  term  acinos  has  been  employed  in  different  senses,  at 


GLANDULAR  TISSUE — ACINI. 


769 


different  periods,  by  different  authors.  The  word  akinos,  acinus,  and 
acinum,  from  the  Greek  ayuwg  and  anovog,  was  used  by  ancient  writ- 
ers to  signify  a grape-stone,  the  kernel  of  a pomegranate,  or  the 
grain  or  stone  of  any  stone-fruit.  By  Glisson,  Wharton,  and  Mal- 
pighi it  was  adopted  to  designate  certain  hypothetical  parts  of  glan- 
dular structure,  into  which  they  thought  that  glandular  structure 
might  be  finally  resolved.  This  Malpighi  studied  to  render  more 
definite  by  saying,  that  in  the  liver  acini  were  small  elementary 
bodies,  hexahedral  or  polyhedral,  or  even  spherical  in  shape  ex- 
ternally, but  with  an  inner  cavity,  and  thickish  parenchymatous 
walls.  These  acini  are  further  called,  both  by  Malpighi  and  Boer- 
haave,  one  of  his  great  defenders,  utriculi,  or  membranous  sacculi. 
These  bodies  Malpighi  represents  to  be  round  and  hollow  in  the 
kidneys. 

To  this  view  Malpighi  probably,  and  Boerhaave  certainly,  was 
led  by  analogy  between  crypts  and  the  ultimate  elements  of  large 
conglomerate  glands. 

Ruysch,  on  the  other  hand,  who  admitted  the  existence  of  acini 
or  acinuli  in  glands,  maintained  that  they  presented  nothing  in 
common  with  crypts,  because  they  appear  not  like  hollow  mem- 
branes, and  because  they  have  no  emissary  canal.  He  further 
maintained  that  these  acini  are  composed  of  the  final  extremities  of 
blood-vessels,  united  so  as  to  form  globular  or  spherical  bodies,* 
and  he  altogether  denies  cavity  and  emissary  tube. 

After  the  time  of  these  anatomists,  the  word  appears  to  have 
been  used  either  without  definite  meaning,  or  in  different  senses. 
At  one  time  and  with  one  set  of  writers  it  means  a clustered  struc- 
ture ; istructura  racemosa) ; with  another  it  is  used  to  designate  a 
granular  structure,  or  a substance  composed  of  minute  granules. 

As,  however,  many  glands  contain  none  of  this  acinated  or  gra- 
nular structure,  Muller  in  a great  degree  renounces  the  term ; 
and  preferably  employs  the  name  of  elementary  particles  of 

GLANDS,  or  ENDS  OR  ROOTS  OF  SECRETING  DUCTS ; bccause  Under 
these  names  may  be  included  the  several  denominations  of  vesicles, 
utriculi,  tubules,  follicles,  cells,  and  canals,  straight  and  serpentine, 
of  which  glands  consist. 

Weber  applies  the  term  acini  to  the  shut  ends  of  the  excretory 

■"  F.  Ruyschii  Epistola  Anatomica  de  Structuia  Glandularum,  ad  H.  Boerhaave, 
p.  69,  70,  Op.  Om.  Tom.  IV. 


770 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


ducts,  which  are  arranged  according  to  their  cellular  projection  ; 
and  also  to  the  primary  lobules  or  their  apices. 

Henle,  like  Muller,  avoids  the  use  of  this  terra  acini.,  by  which 
he  thinks  Malpighi  meant  the  closed  ends  of  excretory  ducts,  and 
which  probably  were  primary  lobules.* 

The  most  recent  authorities  withhold  the  term  for  the  glandular 
vesiculce.  Further,  the  solid  lobules  of  the  liver,  and  especially  the 
cells  of  which  they  consist,  are  named  acini. 

VII.  Tlie  smallest  blood-vessels  pass  not  directly  into  glandular 
parts  and  ends  of  secreting  ducts  ; but  the  blood-vessels  are  distri- 
buted to  the  parietes  of  secreting  canals  exactly  as  to  any  other  se- 
creting membrane.  They  do  not  enter  by  open  ends  into  the  cells 
of  these  canals ; but  they  pass  between  the  elementary  particles  of 
the  glands,  and  upon  these  terminate  by  delicate  networks  into  the 
small  veins.  This  passage  of  blood  between  the  elongated  acini  of 
the  liver  from  one  order  of  blood-vessels  into  another,  may  be  dis- 
tinctly seen  in  the  living  larvae  of  the  triton. 

VIII.  The  system  of  blood-vessels,  therefore,  in  every  glandular 
organ  is  confined  within  certain  definite  limits,  by  means  of  an  in- 
termediate reticular  connection  of  minute  vessels  interposed  between 
the  arteries  and  veins. 

IX.  Of  the  connection  between  lymphatic  vessels  with  the  ex- 
cretory ducts  in  some  glands,  which  has  been  already  noticed  un- 
der its  proper  head,  Muller  is  of  opinion  that  it  is  not  proved  by 
the  alleged  injection  ; and  that  it  is  entirely  accidental. 

X.  Every  system  of  secreting  ducts,  without  any  continuous 
communication  with  blood-vessels,  bounded  and  closed  by  certain 
shut  ends,  is  to  be  viewed  as  an  efflorescence  or  ramification  of  the 
excretory  duct ; because  it  is  proved,  that  in  the  embryo  it  grows 
or  sprouts,  as  it  were,  from  an  excretory  duct,  at  first  unbranched. 

XL  The  ramifications  of  the  blood-vessels  accompany  the  efflo- 
rescence of  the  secreting  canals,  and  with  peripheral  reticular  ves- 
sels wind  on  the  elementary  parts,  and  terminations  of  the  secret- 
ing canals.  As  a follicle  or  intestinula  rise  from  the  uniform  mem- 
brane, and  send  out  repeatedly  several  utriculi  and  canals,  so  on 
the  efflorescing  canals  the  vascular  network  advances,  itself  rising 
from  the  uniform  membrane.  These  facts  are  shown  in  the  phe- 
nomena of  the  incubated  egg. 

* Allgemeine  Anatomie.  Lehre  von  den  Mischnngs-und  P’ormbestandtheilen  des 
Menschlichen  Korpers.  Von  J.  Henle.  Leipzig,  1841.  Seite  922. 

4 


GLANDULAR  TISSUE — DIAMETER  OF  SECRETING  TUBES.  771 


XII.  While  canals,  which  always  in  insects  and  sometimes  in 
the  higher  animals  are  observed  free,  are  progressively  increased 
by  the  new  efflorescence,  and  mutually  approximated,  connected 
by  blood-vessels, — from  these  free  canals  gradually  a species  of 
parenchyma  arises. 

XIII.  The  most  delicate  reticulate  blood-vessels  are  still  much 
smaller  than  the  most  slender  branches  of  the  secreting  canals,  and 
their  terminations  in  the  largest  glandular  viscera.  The  elemen- 
tary parts  of  glands,  therefore,  though  small,  are  nevertheless  al- 
ways so  capacious  that  they  are  enclosed  and  connected  by  the 
smallest  reticulated  blood-vessels.  The  cortical  uriniferous  canals 


are  much  larger  than  the  smallest  blood-vessels  in  all  classes  of 
animals.  In  the  salivary  glands  of  the  mammalia  and  man,  the 
most  delicate  blood-vessels  are  many  times  smaller  than  the  acini 
of  the  salivary  terminal  vesicuM.  The  same  is  true  of  the  pancreas. 
The  free  ends  of  the  salivary  ducts  in  the  hamster  differ  greatly 
from  the  very  smallest  blood-vessels.  The  closed  ends  of  the  bili- 
ferous  ducts  in  the  embryos  of  birds,  amphibia,  and  mammalia  are 
much  larger  than  the  smallest  blood-vessels. 

To  show  the  amount  of  this  relation  of  majority  of  the  secreting 
ducts  to  the  blood-vessels,  and  that  of  the  relation  of  minority  of 
the  blood-vessels  to  the  secreting  ducts,  Muller  gives  the  respective 
diameters  of  these  two  orders  of  tubes  as  determined  by  himself  by 
the  micrometer.  From  these  measurements  a few  examples  are 
here  selected. 


The  smallest  capillary  blood-vessels,  (Weber,) 

The  same  in  kidney,  (Muller,) 

The  same  in  human  iris. 

The  same  in  human  ciliary  processes. 

Smallest  pulmonary  cells  in  man,  (Weber,) 

CyUndriform  mtestinula  in  the  lungs  of  embryo  birds, 

Elementary  vesicles  of  mammae  of  suckling  hedgehog. 

Terminal  cells  in  salivary  ducts  of  goose  filled  with  mercurj'. 
Terminal  cells  of  salivary  ducts  of  parotid  in  man  filled  with  mer- 
cury. 

Cells  of  lacrymal  gland  of  goose  filled  with  mercury. 

Cells  of  pancreas  of  goose  filled  with  mercury. 

Elements  of  lacrymal  gland  of  Testvdo  mydas 
Cells  of  Harderian  gland  of  hare  filled  rvith  mercury, 

Terminal  vesicles  of  biliferous  ducts  of  snail,  {Helix  pomatia) 

Free  terminal  twigs  of  bile-ducts  in  embryos  of  birds, 

Intestinula  of  Wolffian  body  in  embryo  of  bird. 

The  same  from  another  embryo. 


Paris  inch. 
0.00025  — 0.00050 
0.00037  — 0.00058 
0.00037  — 0.00057 
0.00053 

0.00441  —0.01333 
0.00474 

0.00712  — 0.00928 
0.00260 


0.00082 

0.00327 

0.00137  — 0.00297 

0.00194 

0.00776 

0.00565 

0.00172 

0.00377 

0.00300 


772 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Uriniferous  ducts  of  Petromyzon, 

Paris  inch. 
0.00324 

Uriniferous  ducts  from  kidney  of  Torpedo  Marmorala, 

0.004G.9 

Uriniferous  ducts  from  kidney  of  owl  injected  from  ureter  i 

(under 

air-pumj),) 

0.00174 

Cortical  uriniferous  ducts  from  kidney  of  squirrel, 

0.00174 

Serpentine  cortical  uriniferous  ducts  from  kidney  of  horse  injected 

from  ureter,  (under  air-pump,) 

0.00137  — 0.20182 

Medullary  uriniferous  ducts  from  kidney  of  horse  injected 

from 

ureter,  the  largest  near  the  papilla;, 

0.01803 

The  same  from  the  central  medullary  matter, 

0.00489 

The  same  cortical  seen  in  section  of  kidney. 

0.00140  — 0.00188 

Corpmcula  Malpighiana  from  human  kidney,  (Muller,) 

0.00700 

The  same,  (Weber,) 

0.00666  — 0.00883 

Seminal  canals  of  young  cock. 

0.00528 

squirrel, 

0.01453 

hedgehog, 

0.00970 

• man. 

0.00470 

Tuhuli  in  anal  glands  of  goose, 

0.00990 

Clustered  tubuU  in  Cowper’s  glands  in  hedgehog, 

0.01022 

Cells  in  Meibomian  glands  in  man,  (Weber,) 

0.00258  — 0.00633 

XIV.  In  simple  glands,  which  are  composed  of  intestinules  and 
large  follicles,  the  smallest  blood-vessels  wind  along  the  walls  of 
these  intestinules  and  follicles,  exactly  as  in  any  other  animal 
membrane ; for  instance,  the  pulmonic  mucous  membrane.  In 
these  walls  the  transition  of  arteries  into  veins  by  reticular  arches 
takes  place  in  the  usual  manner.  In  compound  glands,  however, 
the  ducts  of  which  are  small  and  very  small,  as  in  the  kidneys, 
liver,  and  testicle,  the  uriniferous,  biliferous,  and  seminiferous 
ducts  are  connected  only  externally  with  the  most  delicate  vascu- 
lar networks,  without  the  vessels  winding  on  the  thin  walls  of  these 
ducts. 

XV.  The  ultimate  distribution  of  the  blood-vessels  does  not  al- 
ways follow  the  formation  of  the  secreting  canals.  In  the  liver  of 
the  embryo,  indeed,  where  the  paniculate  and  pinnatifid  ends  of 
the  biliferous  ducts  spring  from  the  surface,  so  as  to  be  seen  by 
the  microscope,  the  blood-vessels,  though  smaller,  imitate  a similar 
disti’ibution ; for  they  run  in  the  middle  of  a panicula  ovfolwlus, 
and  with  their  final  smallest  capillary  twigs  descend  between  the 
closed  ends  of  the  ducts  or  acini.  But  in  glands  which  are  formed 
of  serpentine  unbranched  ducts,  everywhere  equal  in  diameter,  the 
blood-vessels  are  not  serpentine,  but  with  very  small  branches,  creep 
among  the  gpri  or  turns  of  the  serpentine  ducts. 

XVI.  That  the  smallest  currents  of  blood  run  freely  between 
the  acini  of  a compound  gland,  as  the  liver,  and  that  the  blood  is 


GLMDULAK  TISSUE — VARIETIES  IN  SECRETING  TUBES.  773 

in  immediate  contact  with  the  acini,  has  been  inferred  by  Gruit- 
huisen,  on  the  faith  of  microscopical  observations  on  the  liver  of 
the  frog.  This  inference  Muller  thinks  unfounded.  He  allows 
that  at  first  on  investigating  the  development  of  the  liver  and  kid- 
neys in  the  embryo,  such  appears  to  be  the  fact.  The  blood-in- 
terstices of  the  canals  appear  without  certain  trace  of  parietes  of 
vessels ; and  the  same  appearance  is  presented  by  the  microscopical 
e.xaniination  of  the  liver  in  live  larvEe  of  Tritons.  But  Muller  is 
satisfied  from  microscopical  observations  on  the  kidneys  of  adults, 
both  after  injection  and  recent,  that  vestiges  of  the  most  minute 
blood-vessels  are  formed  in  the  tissue  which  unites  the  uriniferous 
canals.  Muller  allows,  nevertheless,  that  at  first  new  currents, 
without  proper  walls,  are  formed  in  an  amorphous  web ; but  imme- 
diately walls,  however  thin,  as  more  fixed  boundaries  to  these  cur- 
rents, are  formed  by  increased  thickness  of  the  substance  round  the 
currents. 

XVII.  The  development  of  the  glands  in  the  embryos  of  the 
higher  animals  takes  place  in  the  same  manner  as  the  glands  in  the 
series  of  animals  generally.  That  is  the  most  complex  glands  in 
the  embryo  of  the  higher  animals  consist  at  first  of  excretory  ducts 
alone,  similar  to  the  secreting  vessels  of  the  lower  animals. 

XVIII.  The  intimate  structure  of  the  glands  presents  very  many 
varieties,  chiefly  with  the  object  of  increasing  the  extent  of  secret- 
ing surface.  Tet  no  species  of  structure  is  peculiar  to  any  indivi- 
dual gland.  In  the  most  difierent  glands  the  structure  may  be  the 
same,  as  in  the  cortical  substance  of  the  kidney,  and  in  the  testicle. 
Conversely  the  same  gland  presents  a ditferent  structure  in  differ- 
ent animals.  For  instance  the  lacrymal  gland  in  the  tortoise  con- 
sists of  fasciculated  utriculi^  forming  a cortex  or  rind  around  the 
excretory  ducts.  In  birds  the  same  gland  is  cellulated ; in  the 
mammalia  it  consists  of  pedunculated  vesicles,  with  ducts  appended 
in  the  form  of  clusters.  The  minute  structure  of  the  liver  and 
testicles  in  like  manner  presents  great  variations.  The  kidneys 
alone,  in  all  classes,  observe  one  common  model  of  formation,  from 
uniform  canals  unbranched,  either  straight  or  tortuous,  though  the 
disposition  and  walls  of  the  canals  undergo  the  greatest  diversity  in 
different  classes. 

XIX,  The  structure  of  glands  increases  in  complication  in  the 
series  of  animals  up  to  man  ; yet  tliis  increase  in  complication  is  not 
always  in  the  same  ratio.  The  rule  seems  to  be  that  in  every  class 


774 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  gland  which  appears  first  presents  the  most  simple  formation. 
Thus  the  pancreas  is  the  most  simple  in  fishes,  the  liver  in  the  lower 
classes  of  animals,  and  the  kidneys  in  fishes  and  amphibia.  And 
when  any  gland  appears  first  in  any  order  of  animals,  it  is  formed 
either  of  intestinules  or  follicles,  or  tubules. 

XX.  The  substance  of  the  canals  in  the  glandular  tissue  is  either 
whitish,  or  whitish-gray,  or  whitish-orange,  however  different  be  the 
colour  of  the  secreted  products.  There  is,  therefore,  no  perfect  re- 
semblance between  the  glandular  substance  and  the  secreted  pro- 
duct, as  has  been  erroneously  staled  by  several  writers. 

XXL  The  elementary  parts  of  glands,  viz.  cells,  vesicles,  utri- 
culi,  follicles,  tubules,  &c.,  always  consist  of  one  single  tissue.  The 
excreting  duct  only  consists  sometimes  of  several,  sometimes  of  two 
membranes,  the  inner  of  which,  being  usually  continuous  with  the 
mucous  membrane,  is  generally  of  the  same  nature,  while  the  ex- 
ternal passes  in  the  substance  of  the  gland  into  the  proper  substance 
of  the  canals.  The  other  external  membranes  of  the  excretory 
ducts,  fibrous,  or  adventitious  cellular,  terminate  in  the  beginning 
of  the  gland,  are  sometimes  continued  in  the  fibrous  investment  of 
the  gland,  as  in  the  poison-gland  of  serpents.  In  certain  cases  the 
fibrous  investment  of  a gland  transmits  processes  between  the  seg- 
ments and  lobules,  as  in  the  poison-glands  of  the  Trigonocephalus, 
in  the  salivary  glands  of  serpents  and  Birds,  and  in  the  anal  glands 
of  the  mole.  The  gland  is  then  divided  into  compartments,  and 
the  lobules. are  contained  within  septa  or  partitions,  though  exter- 
nally it  appears,  and  is  erroneously  considered  to  be,  uniformly 
parenchymatous.  More  frequently,  however,  the  lobules  of  a gland 
are  united  by  loose  cellular  tissue  and  vessels. 

XXII.  The  nerves  of  glands  accompany  the  arteries  and  veins 
in  general  regularly,  and  form  slender  plexuses  over  the  large 
branches  ; and  nowhere  do  the  nerves  separate  from  the  blood-ves- 
sels ; so  that  they  may  be  regarded  as  rather  foreign  to  the  glandu- 
lar structure. 

XXIII.  These  ducts,  canals,  or  intestinula,  are  all  lined  or  form- 
ed internally  or  at  the  free  surface  by  a membrane  continuous  with 
some  mucous  membrane.  This  membrane  has  been  called  epithe- 
lium by  the  revival  of  a name  formerly  in  use.  It  consists  of  cells, 
mostly  nucleated,  mingled  with  granules  irregularly  dispersed. 
These  cells  are  clear  and  colourless,  but  often  scattered  with  small 
punctvlu.  The  nucleus  is  round  or  oval,  from  ,550  to  ^555  of  a 
I'aris  inch  in  diameter,  more  or  less  flat,  generally  colourless  or 


STKUCTURE  OF  INDIVIDUAL  GLANDS — SALIY.UIY  GLANDS.  775 

pale-red,  like  blood-globules.  These  epithelial  cells  are  believed 
to  be  detached  from  time  to  time  in  the  form  of  scales. 

Section  II. 

THE  STRUCTURE  OF  INDIVIDUAL  GLANDS. 

The  previous  observations  are  general.  It  is  requisite  now  to 
advert  shortly  to  the  structure  of  individual  glands.  This  struc- 
ture is  best  understood  by  tracing  it  in  the  embryo. 

§ I. THE  SALIVARY  GLANDS. 

As  an  example  we  may  take  the  parotid. 

When  the  parotid  gland  is  examined  in  the  embryo  of  the  sheep 
or  the  ox,  it  appears  that  it  is  developed  or  formed  by  a species  of 
progressive  ramification  from  the  mucous  membrane  of  the  mouth. 
The  excretory  duct,  in  short,  which  is  first  formed,  is  a prolonga- 
tion of  the  mucous  membrane  of  the  mouth.  It  appears  at  an  early 
period  in  the  form  of  a whitish  semitranslucent  canal,  extending  in 
an  arched  curvature  towards  the  ear,  dividing  into  several  very 
short  branches  scarcely  smaller  than  the  trunk.  These  branches  ter- 
minate in  a blind  or  vesicular  close  cavity,  slightly  swelling  ; and  this 
disposition  is  retained  throughout  the  whole  period  of  the  formation 
of  the  gland.  This  branchy  arrangement  is  well  distinguished  in 
the  midst  of  a pellucid  jelly-like  matter,  which  was  regarded  by 
Rathke  as  primordial,  or  the  blastema.  Afterwards  tbis  jelly-like 
matter  becomes  opaque,  and  is  divided  into  roundish  flattened  lo- 
bules. These  dilated  vesiculoe  or  ampullulce  form  the  ultimate  gra- 
nules or  elementary  parts  of  the  gland. 

The  arrangement  of  the  twigs  and  branches  is  the  following. 
The  excretory  duct  is  divided  into  long  whitish  canals.  From  these 
proceed  long  lateral  branches  scarcely  smaller  than  the  trunks. 
Each  of  these  goes  to  a lobule  and  sends  branches  into  it ; in  such 
manner,  however,  that  the  twigs  then  arising  are  scarcely  smaller 
than  the  trunks.  These  twigs  again  send  out  new  stalks,  which  all 
terminate  in  large  rounded  bladders  or  vesiculcB. 

All  the  canals  are  white,  even  to  the  extreme  tips  of  the  twigs, 
and  they  wind  about  in  the  same  plane  of  flattened  lobules,  pre- 
senting under  the  microscope  an  interesting  object. 

It  is  further  to  be  remembered  that  this  ramification  is  only 
lateral,  that  is  from  each  side  or  margin  of  the  duct  and  branches. 


776  GENERAL  AND  PATHOLOGICAL  ANATOMY. 

and  not  all  round  or  peripheral.  It  appears  that  the  same  lateral 
ramification,  with  the  same  arrangement  of  lobules,  takes  place  in 
the  lacrymal  gland,  and  in  the  mammae. 

The  blood-vessels  do  not  follow  these  ramifications  so  much  as 
the  blastema,  or  primordial  matter,  to  which  they  are  nutrient 
canals. 

As  the  ooum  or  embryo  grows,  this  growth  of  ramification  or 
branching  like  a plant  proceeds ; and  as  this  advances  in  producing 
shoots  and  pedunculated  vesicles,  the  blastema  or  primordial  mat- 
ter of  the  lobules  is  consumed ; the  internal  ramification  towards 
the  margin  of  the  lobules,  originally  spacious,  advances ; and 
branches  formerly  dispersed  in  the  place  of  the  lobules  are  accumu- 
lated over  each  other. 

The  vegetation  of  the  ducts  of  the  submaxillary  gland  differs  a 
little  from  that  of  the  parotid,  according  to  Rathke,  and  approaches 
that  of  the  pancreas. 

§ II. THE  PANCUEAS. 

The  arrangement  representing  this  gland  in  fishes  has  already 
lieen  noticed. 

In  the  Mammalia,  this  organ  having  passed  through  different 
stages  in  reptiles  and  birds,  presents  the  following  characters. — 

In  the  foetus  of  the  sheep  of  four  inches,  the  elementary  particles 
of  the  ]>ancreas  have  already  consumed  almost  their  whole  blastema, 
so  that  scarcely  a trace  of  the  common  amorphous  primordial  sub- 
stance remains.  The  elementary  particles  are  everywhere  freely 
lirominent.  These  consist  of  elongated  cylindrical  acini  or  bunchy 
idriciili,  which  are  larger  than  the  pedunculated  vesicles  of  the  sa- 
livary glands,  and  are  so  generally  conjoined,  that  they  constitute 
poniculce  everywhere  scattered  on  the  surface.  These  cylindrical 
acini,  or  elementary  utriculi,  proceed  alternately  from  the  middle 
twig,  form  elsewhere  pinnatifid  paniculce,  as  in  the  pancreas  of 
birds.  In  other  respects  they  are  all  very  white,  equal,  not  pedun- 
culated, gently  expanding  in  a shut  end.  In  each  set  of  three,  four, 
or  five  panicidce,  Muller  observed  prominent  shoots ; the  rest,  if 
there  were  more,  were  covered  by  the  neighbouring  paniculce.  The 
shoots  composing  one  single  panicula  are  unfolded  in  the  same 
jilace ; and  in  this  respect  they  manifestly  differ  in  structure  from 
the  parotid  gland.  The  intimate  union  of  the  puniculcE  Muller  was 
unable  to  unravel. 


STRUCTURE  OF  INDIVIDUAL  GLANDS — LIVER. 


777 


In  the  Hamster  ( Cricetus  vulgari&\  the  pancreas  consists  of  very 
small  lobules,  which  are  almost  entirely  separate  from  each  other, 
and  adhere  only  loosely  by  the  different  ducts,  forming  large  lobules. 
The  elementary  particles  are  the  same  almost  as  in  the  salivary  glands, 
but  half  more  slender  ; nor  does  the  middle  part  of  the  canal  appear 
white  as  in  the  salivary  glands.  Each  lobule  divided  into  small 
fasciculi,  or  clusters,  or  elementary  parts,  receives  in  the  middle  a 
blood- vessel,  which  is  distributed  in  twigs  among  the  smaller/ascfcM?f. 

The  summary  of  the  structure  of  the  pancreas  is  the  following. 
In  Amphibia,  Birds,  and  IMammalia,  in  the  foetal  state,  there  is 
observed  a paniculated  vegetation  of  acini,  or  elongated  cylindrical 
utriculi  or  bladders  ; the  cylindrical  acini  in  the  paniculcB,  proceed 
from  a middle  twig  like  the  nerves  of  leaves  ; .and  all  terminate  in 
free,  shut,  and  slightly  swelling  ends.  In  adult  birds,  the  secreting 
canals  begin  in  cellular  roots  or  very  crowded  small  vesicles. 

* § III. THE  LIVER. 

In  the  surface  of  the  liver  of  the  sturgeon,  Muller  observed  with 
the  microscope  small  pinnatifid  paniculm  variously  dispersed,  so 
that  the  acini  or  roots  of  the  biliferous  canals  were  united  in  the 
pinnatifid  manner.  The  sprouts  were  otherwise  free,  slightly 
swelled  at  the  tip. 

In  the  toad  the  formation  is  the  following  ; — 

The  proliferous  membrane,  after  surrounding  the  yelk  by 
growths  in  all  directions,  forms  a saccated  appendix,  pendulous  from 
the  keel  of  the  embryon,  containing  the  substance  of  the  yelk. 
That  sac  is  divided  into  an  external  very  thin  pellucid  layer,  and 
an  internal  vascular  layer,  one  of  which  belongs  to  the  integu- 
ments, and  the  other  to  the  intestines.  The  inner  sac  is  soon  pro- 
longed towards  the  vertebral  column,  into  an  anterior  and  posterior 
lacinia,  which  indicate  respectively  the  anterior  and  posterior  ends 
of  the  intestinal  canal.  When  the  anterior  prolongation  issues 
from  the  common  sac,  on  the  right  side,  in  the  continuation  of  the 
sac  of  the  yelk,  is  seen  conspicuously  a whitish  swelling,  consisting 
of  globules,  with  slender  peduncles,  as  it  were,  attached.  Observed 
casually  granules  appear,  and  these  are  the  first  vestige  of  the 
liver.  The  sac  of  the  yelk  is  distinguished  by  innumerable  reti- 
cular blood-vessels,  in  which  the  blood  is  observed  moving  dis- 
tinctly. 

After  one  or  two  days,  the  beginning  and  end  of  the  intestinal 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


sac  are  more  elongated;  and  the  circular  motion  of  the  blood 
most  fully  evolved  in  the  intestinal  sac,  is  distinguished  by  innu- 
merable arches  of  reticulated  vessels.  A trunk  of  veins  bends  to 
tbe  right,  and  seems  to  proceed  under  the  liver,  where  it  sends  se- 
veral small  vessels  into  the  liver.  The  liver  itself,  situate  in  the 
anterior  prolongation  of  the  intestinal  sac,  is  known  by  its  whiten- 
ing, elongated,  almost  pedunculated  acini.  These  might  be  called 
vesiculcB.,  if  it  could  be  proved  that  they  are  already  hollow. 

In  grown  animals,  the  principal  difference  is  in  the  greater  dis- 
tinctness with  which  the  vessels  and  the  contained  blood  are  seen. 

The  substance  of  the  liver  is  very  tender,  is  turned  from  tawny 
into  white,  not  unlike  the  substance  of  the  yelk  : it  consists  of 
elongated  acini.,  variously  disposed,  similar  almost  to  the  elongated 
bundles  of  acini  in  the  embryo  of  birds  ; only  these  are  in  Birds 
more  distinct  and  freely  prominent. 

As  to  the  liver  of  Birds,  the  observations  of  Baer  deserve  notice. 
He  states,  that  from  the  swelled  vascular  fayer  of  the  alimentary 
canal  are  developed,  in  the  course  of  the  third  day  after  impregna- 
tion, the  lungs,  the  liver,  the  pancreas,  the  cmcum,  and  the  urinary 
bladder.  All  these  parts  are  developed  from  the  closed,  not  the 
open  end  of  the  alimentary  canal,  while  the  mucous  membrane  of 
that  canal  is  covered  with  the  proportional  tubes  in  the  vascular 
layer. 

The  liver  appears,  about  the  middle  of  the  fourth  day,  as  two 
pyraraid-like  hollow  limbs  of  the  intestinal  canal,  which  enclose  the 
common  venous  trunk,  and  pass  with  their  broad  basis  into  the  ali- 
mentary canal.  Scarcely  have  these  pyramids  clasped  the  veins, 
when  they  are  prolonged  into  the  next  containing  part  of  the  vas- 
cular layer,  and  are  ran)itied  in  it,  a covering  from  the  vascular 
membrane  at  the  same  time  urging  them  forward.  The  protruded 
portions  appear,  with  increasing  prolongation  and  contraction  of 
the  alimentary  canal,  leaf-like,  and  closely  embracing  the  veins. 
In  these  leaves  appear  the  tips  of  the  advancing  quills,  while  their 
basis  is  progressively  narrowed,  and  assumes  the  form  of  a cylinder. 
The  ramification  appears  under  the  microscope  as  a branching  dark 
figure  in  the  inside  of  each  leaf. 

As  soon  as  the  quill-like  prolongations,  which  form  the  future 
hepatic  ducts,  begin  to  take  the  cylindrical  form,  there  appears  among 
them  a retraction  which  increases  gradually,  so  that  at  the  end  of 
the  third  day  they  scarcely  reach  the  middle  of  the  substance  of 
the  vascular  layer,  and  externally  they  form  nowhere  any  projec- 


STRUCTURE  OF  INDIVIDUAL  GLANDS LIVER. 


779 


tion.  The  granular  inner  layer  presents  at  the  apex  some  ramifi- 
cation ; which  evidently  has  the  aspect  of  mucous  cavities. 

On  the  fourth  day,  the  vascular  layer  is  still  farther  removed, 
and  resembles  semitransparent  jelly ; the  liver  is  divided  into  two 
flat  bodies,  which  surround  like  plates  the  portal  vein.  In  these 
plates  both  hepatic  ducts  undergo  further  ramification,  but  at  the 
same  time  at  a greater  distance  from  the  bowel,  so  that  most  com- 
monly they  are  united  at  the  bases,  and  at  the  end  of  the  fourth 
day  are  wont  to  form  one  common  canal. 

After  this  the  progress  is  similar,  only  to  render  the  vascular  and 
secreting  parts  more  distinct.  On  the  eighth,  ninth,  and  tenth  day, 
the  gall-bladder  appears. 

In  short,  the  liver  is  formed  in  the  following  manner  : by  ever- 
sion of  the  internal  tunic  of  the  intestinal  canal  into  the  vascular 
layer,  whence  a double  excavated  cone  arises.  These  two  excavated 
cones  are  then  ramified  internally,  though  united  at  the  base,  the 
common  basis  being,  as  it  w'ere,  prolonged  from  the  intestinal  wall, 
until  the  two  orifices  open  in  one  common  orifice. 

In  the  Mammalia,  the  terminations  of  the  biliferous  ducts  end 
exactly  as  in  birds,  free  and  in  shut  extremities ; but  in  their  in- 
ternal union  they  seem  to  diflFer  in  each,  so  that  in  some  the  elon- 
gated acini  are  joined  in  the  pinnatifid  manner,  in  others  like 
leaves,  and  in  others  irregularly. 

Next  to  the  arrangement,  disposition,  and  form  of  the  secreting 
ducts  comes  that  of  the  blood-vessels. 

The  branches  and  twigs  of  the  portal  vein  everywhere  rise  to  the 
surface  of  the  liver,  and  follow  chiefly  the  distribution  of  the  bili- 
ferous ducts  ; while  the  branches  of  the  hepatic  artery  traverse  the 
surface  in  a peculiar  manner.  Of  the  twigs  of  the  portal  vein  it  is 
a peculiar  character,  that  they  are  more  conical ; while  the  arterial 
twigs  diminish  their  diameter  very  gradually,  and  are  distributed  in 
a sinuous  course  so  irregularly,  that  it  is  difficult  to  distinguish 
trunks  from  branches. 

The  smallest  blood-vessels  are  much  more  minute  than  the  elon- 
gated ends  of  the  biliferous  ducts. 

The  smallest  blood-vessels  in  the  embryo  of  Birds,  and  the  larvcR 
of  tritons  and  frogs,  are  not  distributed  on  the  walls  of  the  bilife- 
rous ducts ; but  run  in  the  intervals  between  their  bundles  and 
sprouts. 

There  is  no  direct  communication  between  afferent  vessels,  whe- 


780 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


ther  portal  or  arterial,  and  revehent  vessels.  In  all  cases  tliere  is 
an  intermediate  network  of  very  minute  capillaries,  that  is,  vessels 
all  of  the  same  diameter,  and  all  frequently  and  freely  communi- 
cating with  each  other.  It  is  therefore  a mistake  to  say  that  a 
blood-vessel  terminates  in  a biliferous  duct.  If  this  be  the  case,  no 
one  has  ever  seen  it,  even  by  the  microscope ; and  the  phenomena 
which  are  supposed  to  prove  it,  are  irregular,  or  the  result  of  certain 
fallacies. 

In  1833,  Mr  Kiernan  published  a description  of  the  minute 
anatorny  of  the  liver.  He  arrived  at  the  conclusion  that  each  lobule 
is  composed  of  numerous  minute  bodies  of  a yellowish  colour,  im- 
parted to  them  by  contained  bile,  and  of  various  forms,  connected 
with  each  other  by  vessels.  These  bodies  he  regards  as  the  acini 
of  Malpighi.  Each  of  these  lobules  consists  of  a plexus  of  biliary 
ducts,  of  a venous  plexus  formed  by  branches  of  the  portal  vein, 
of  a branch  of  an  hepatic  vein,  and  of  minute  arteries.  Nerves  and 
absorbents  he  did  not  trace  into  them.  He  showed  also  that  the 
hepatic  veins  do  not  communicate  with  the  branches  of  the  portal 
vein  ; that  the  interlobular  branches  of  the  latter  form  one  conti- 
nuous plexus  through  the  whole  liver ; that  the  portal  veins  have 
no  direct  communication  with  each  other,  but  anastomose  by 
means  of  interlobular  branches  only ; and  that  the  portal  vein, 
accompanied  by  an  artery,  resembles  an  artery  in  its  ramifications.* 

According  to  Henle,  the  microscope  shows  that  the  acini  of  the 
liver  are  formed  in  a quite  different  way  from  all  other  glandular 
lobules.  They  are  heaps  of  closely-crowded,  and  everywhere  closed 
nucleated  cells,  which  entirely  fill  up  the  meshes  or  intervals  be- 
tween the  blood-vessels. 

In  a fine  section  of  a hepatic  lobule,  these  nucleated  cells  are 
seated  without  the  walls  of  the  blood-vessels,  sometimes  in  irregular 
heaps,  sometimes  in  irregular  short  rows  close  to  each  other,  which, 
if  these  transverse  divisions  be  examined,  appear  like  minute  blood 
intestinula.  The  medium  diameter  of  these  cells  is  about 
parts  of  a Paris  line ; the  nucleus  is  usually  round,  compressed, 
somewhat  flat,  from  idVoo  to  -joilo  parts  of  a Paris  line  in  diame- 
ter, with  one  or  two  nucleated  granules.  By  the  mutual  pressure 
of  the  cells  on  each  other  they  become  polygonal,  tetrahedral,  or 

* Tlie  Anatomy  and  Physiology  of  the  Liver.  By  Francis  Kiernan,  Esq.  4to. 
London,  1834.  Philosojihical  Transactions  of  the  Royal  Society  of  London  for  1833^ 
Part  II. 


STPJICTURE  OF  INDIVIDUAL  GLANDS — KIDNEYS. 


781 


pentahedral.  Their  colour  is  yellowish.  They  contain  a quantity 
of  fine  punctuated  corpuscula,  which  appear  to  be  seated  on  their 
walls,  and  frequently  in  man  and  mamraiferous  animals,  small  and 
large  fat  globules,  which  are  never  seen  in  perfectly  sound  livers. 
Not  unfrequently  there  are  small  cells  which  inclose  the  narrow 
nucleus  and  large  cells  with  two  nuclei;  and  some  there  are,  the 
cavities  of  which  communicate  with  each  other,  or  between  which 
certainly  no  partition  is  visible.  Hallmann  found  cells  without 
nuclei ; that  is,  non-nucleated  cells. 

Besides  these  cells,  we  see  only  fat  in  the  intervals  of  the  lobules, 
fibres  in  the  walls  of  the  strong  vessels  and  biliferous  ducts,  and 
cylindrical  epithelial  cells  detached  from  the  last.  Henle  could 
not  observe  on  the  surface  of  the  lobes  or  between  them  any  peculiar 
ligamentous  tissue  ; and  Vogel  says  that  it  appears  doubtful.* 

These  cells,  there  is  every  reason  to  believe,  perform  an  import- 
ant part  in  tbe  formation  of  bile. 

§ IV. — THE  KIDNEYS. 

The  kidneys  and  testes  are  referred  by  Henle  to  the  head  of  Re- 
ticulated or  Net-like  glands. 

The  substance  of  the  kidneys  in  fishes  consists  of  long  canals  of 
equal  diameter,  which  arise  from  branches  of  the  ureter,  or  pa- 
rallely  in  bundles  from  the  lateral  ureter,  and  proceed  sometimes 
straight,  sometimes  in  a sinuous  course  variously  contorted,  without 
being  divided  into  branches,  which  are  not  attenuated  towards  the 
extremities,  but  terminate  uniformly  in  short  ends. 

In'  reptiles,  the  vesiculcE  or  bladders  of  tbe  secreting  apparatus, 
or  ends  of  the  uriniferous  ducts,  arise  before  the  ureter  itself  is  dis- 
tinctly seen.  This  seems  to  show  that  the  development  of  the  kid- 
neys begins  from  the  peripheral  vesicles.  The  stalks  of  these  ve- 
sicles are  prolonged  daily,  by  which  the  tubules  terminated  by  ve- 
sicular rounded  apices  arise,  while  the  vesiculcB  themselves  are  more 
and  more  attenuated,  until  the  uriniferous  ducts  observe  the  same 
diameter  to  their  shut  end.  In  short,  in  this  order  of  animals,  the 
substance  of  the  kidneys  consists  of  equal  cylindrical  tubules  rising 
from  the  ureter  and  ascending  to  the  outer  margin  of  the  kidney, 
where  they  terminate  in  short  extremities. 

* Allgem eine  Anatomic.  Lehre  von  cler  Mischungs-und  Formbestandstheilen  des 
Menschbchen  Kdrpers.  Von  J.  Henle.  Leipzig,  1841.  8vo.  See  also  Ueber  der 
Feineren  Ban  der  Leber.  Von  C.  Krause  in  Hanover.  Muller’s  Archiv,  1845.  No.  V. 
seite  524. 


782 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


In  adult  serpents,  the  kidneys  consist  of  many  lobules,  which  are 
connected  in  order  by  the  ureter,  which  passes  along  the  internal 
margin.  The  lobules  on  the  flat  surface  of  the  kidney  are  less 
distinct  than  those  on  its  convex  surface.  All  the  lobules,  however 
are  very  closely  connected.  The  lobulated  appearance,  indeed,  is 
the  result  of  the  undulated  flexures  of  the  renal  mass.  When  the 
substance,  inflected  in  the  undulated  fashion,  is  confined  and  con- 
tracted by  the  ureter,  each  lobule  consists  of  a convoluted  tract,  or 
of  a sort  of  arch,  with  a median  furrow  left.  Into  these  median 
turrows  on  the  one  side  enter  the  bundles  of  the  uriniferous  ducts ; 
and  on  the  other  the  blood-vessels.  And  as  the  lobules  arise  by 
alternating  flexures,  the  bundles  of  the  uriniferous  ducts  being  on 
the  one  margin,  and  the  vascular  trunks  on  the  opposite  one,  the 
former  are  mostly  distributed  on  the  convex  surface,  and  the  latter 
on  the  plane  surface  of  the  kidneys. 

The  kidneys  of  the  crocodile  are  also  lobulated  ; but  the  lobules 
are  not  attached  in  order  to  the  ureter,  as  in  serpents,  but  are 
united  into  an  irregular  mass,  and  receive  the  ureter  internally. 
All  the  lobules  are  contorted,  and  surround  the  surface  with  wind- 
ing  gyri.  When  a kidney  is  divided  transversely  on  the  surface, 
through  the  gyri  of  the  lobules,  the  section  of  the  lobule  or  gyrus 
is  pyramidal.  This  shows  that  the  gyri  of  the  lobules  project  with 
an  external  acute  border,  and  are  united  internally  at  their  bases, 
where  they  receive  the  branches  of  the  ureter.  The  ureter  itself 
appears  to  be  ramified  on  the  deep  substance  of  the  kidney,  so  that 
the  branches  pass  everywhere  into  internal  gyri^  according  to  the 
arrangement  of  the  lobules. 

In  Birds  at  the  first  period  of  development,  when,  besides  the 
heart  and  the  first  rudiment  of  intestine,  the  other  bowels  of  the 
trunk  are  not  yet  visible,  on  each  side  near  the  vertebral  column 
appears  an  elongated  body,  extending  from  the  site  of  the  heart, 
almost  along  the  whole  keel  of  the  embryo.  This  body  observers 
first  mistook  for  the  kidney.  Rathke  showed,  however,  that  this 
body  is  peculiar  to  the  embryon  ; that  it  precedes  and  prepares  for 
the  formation  of  the  testes  and  ovaries,  and  then,  as  the  foetus  ad- 
vances in  maturity,  it  becomes  shorter,  and  at  the  close  of  foetal  life 
vanishes  entirely.  These  bodies,  which  were  first  described  by 
Wolff,  and  therefore  received  the  name  of  Wolffian  bodies  ( Corpora 
Wolffiana),  and  by  Burdach,  were  called  spurious  kidneys,  consist  ^ 
at  first  of  elongated  pedunculated  vesicles,  which  being  arranged 
transversely,  issue  from  one  common  marginal  excretory  duct,  which 


STRUCTURE  OF  INDIVIDUAL  GLANDS — KIDNEYS. 


783 


are  gradually  elongated  into  very  small  intestinula  caca  or  tubules, 
also  transversely  placed.  These  tubules,  at  first  straight,  are  gra- 
dually curved,  until  their  course  becomes  serpentine.  They  are, 
however,  at  all  times  separated  from  each  other,  and  without  trace 
of  ramification. 

Rathke  observed  the  first  rudiment  of  kidneys  on  the  sixth  day, 
and  the  ureter  in  the  form  of  a slender  filament  on  the  seventh 
day  ; while  the  Wolffian  bodies  are  still  of  considerable  size,  and 
have  extended  the  whole  length  of  the  keel  on  the  fourth  day.*  It 
is  further  ascertained,  that  the  Wolffian  bodies  already  present  the 
characteristic  structure,  namely,  transverse  tortuous  intestinula, 
when  the  first  traces  of  kidneys,  like  a mass  of  very  tender  grey 
substance,  appears  close  to  and  behind  the  Wolffian  bodies. 

It  is  the  opinion  of  Rathke,  that  the  substance  of  the  kidneys  is 
formed  from  the  Wolffian  bodies,  because,  on  the  sixth  and  seventh 
day  of  incubation,  when  these  bodies  are  detached  from  the  keel, 
the  kidneys  adhere,  not  to  the  keel,  but  to  the  Wolffian  bodies. 
The  view  of  Muller  is  different.  The  Wolffian  bodies,  according 
to  him,  however,  similar  to  the  kidneys  in  Batrachoid  reptiles,  yet 
diflfer  entirely  in  texture  from  the  kidneys  in  other  Amphibia  and 
in  Birds  ; the  first  trace  of  uriniferous  ducts  being  widely  different 
from  the  intestinules  of  the  Wolffian  bodies.  Muller  further^never 
could  recognise,  after  very  frequent  observation,  any  internal  and 
organic  communication  between  these  organs ; the  closed  intesti- 
nules of  the  Wolffian  bodies  being  at  one  part,  and  at  another  the 
uriniferous  ducts,  arranged  in  brilliant  convolutions,  also  closed  and 
whitish.  Another  circumstance  which  places  this  question  out  of 
all  doubt  is,  that  in  Batrachoid  Amphibia,  the  Wolffian  bodies, 
though  at  first  sought  in  vain,  Muller  found  in  the  upper  part  of 
the  abdomen,  where,  at  a great  distance  from  the  kidneys,  they  are 
provided  with  their  excretory  duct,  and.  consist  also  of  minute  cffica. 
From  these  facts  Muller  infers,  that  the  Wolffian  bodies  have  an 
intimate  connection  with  the  development  of  the  organs  of  genera- 
tion, as  Rathke  first  suspected. 

The  substance  of  the  kidneys,  on  the  other  hand,  is  formed  from 
its  own  proper  blastema  or  primordial  matter,  by  an  innate  effort. 

When  the  mass  of  gray  substance,  situate  at  the  margin  and  be- 
hind the  upper  part  of  the  Wolffian  body,  is  examined  at  its  first  ap- 
pearance by  the  microscope,  the  surface  is  distinguished  by  a ver- 


■*  By  the  Carina  or  keel  is  meant  the  vertebral  column,  or  what  represents  it. 


784 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


micular  eruption  and  varied  appearance  of  gyri  or  convoluted  lines, 
which  are  in  different  parts  convex  and  concave ; and  these  gyri 
again  converge  everywhere  into  the  foliated  form,  like  the  leaves 
of  the  oak,  fig  tree,  or  cauliflower,  variously  arranged  with  undu- 
lated margin.  The  whole  kidney  at  this  period  consists  of  mere 
leaf-like  convoluted  gyri.  These  gyri  form  the  uppermost  part  of 
the  substance ; but  they  are  continued  inwards,  as  if  they  were 
held  together  in  the  deep-seated  substance  by  one  common  mesen- 
tery. When  the  small  masses  deep  in  the  middle,  undulated  at 
margin,  and  also  beyond  the  margin,  are  aiTanged  like  leaves,  the 
observer  thinks  he  sees  the  elementary  particles  of  the  renal  sub- 
stance in  the  prominent  lobules  of  the  gyri. 

At  first  the  gyri  of  the  masses  appear  everywhere  with  unequal 
margin.  Soon,  however,  by  the  aid  of  the  microscope,  there  is 
seen  on  the  tortuous  border  a vesicular  eruption  like  pearls  ; that 
is,  in  the  tender  substance  of  the  tortuous  border,  round  cor- 
puscles are  contained  one  after  the  other ; but  when  these  are 
carefully  examined,  they  are  found  to  he  round  on  the  margin 
only  ; and  below,  where  the  gyri  penetrate  into  the  interior  sub- 
stance, these  corpuscula  also  descend,  and  in  their  course  become 
smaller,  as  the  pedunculi  proceed  from  the  deep  seated  substance, 
and  are  unfolded  variously  on  the  tortuous  and  curled  border  of 
the  gyri.  These  pedunculated  corpuscles  are  whiter  than  the  rest 
of  the  very  tender  substance,  and  are  arranged  one  beside  the  other 
in  very  regular  order,  held  together,  as  it  were,  by  one  common 
mesentery,  which,  folded  and  contracted  inwardly,  but  outwardly 
unfolded  by  innumerable  gyri  and  a tortuous  margin,  produces  a 
remarkable  resemblance  to  the  arrangement  of  leaves  and  lobules. 
In  the  same  manner  the  pedunculi  meet  in  various  points  in  the 
deep-seated  substance,  and  outwardly  are  unfolded  in  the  undulat- 
ing fashion,  terminating  in  a vesicular  or  headed  end.  These  pe- 
dunculi, though  approximated  internally,  are  not  really  united,  but 
merely  approximated  in  the  contracted  membranous  substance. 
This  may  be  regarded  as  tbe  earliest  conformation  in  most  embryos. 

The  arrangement  therefore  is,  that  the  appearance  of  granules 
takes  place  first  on  the  margin  of  the  gyri ; while  the  vesicles  with 
peduncles  are  in  the  deep-seated  substance. 

The  further  development  consists  in  this,  that  the  gyri  of  the  ^ 
uriniferous  ducts  increase  daily,  and  the  undulated  margin  is  con- 
tracted into  several  contorted  lobules,  whence  a more  profuse  leaf-  | 


I 


STRUCTURE  OF  INDIVIDUAL  GLANDS — THE  KIDNEY.  785 


like  vegetation  results,  so  as  to  fill  the  intervals  between  the  gyri ; 
and  the  leaf-like  shape  of  the  lobules  is  gradually  obscured.  The 
kidneys  now  are  parted  into  several  distinct  masses  united  by  the 
ureter. 

At  length  all  the  uriniferous  ducts  send  out  near  their  ends  se- 
veral lateral  knots,  from  which  arise  short  branches  scarcely  smaller 
than  the  tru’-k,  and  terminate  in  short  ends.  This  causes  the  pin- 
natifid  shape  in  the  apex  of  each  uriniferous  duct.  These  ducts, 
pinnatifid  at  end,  are  quite  separate  from  each  other,  and,  though 
arranged  in  regular  order,  have  no  mutual  communication. 

About  the  close  of  foetal  life,  the  uriniferous  ducts,  at  first  white, 
are  now  everywhere  filled  with  a secretion  which  from  being  tawny 
becomes  bright  white,  which  fills  the  canals  almost  to  their  ends, 
and  is  best  seen  in  the  first  days  after  hatching ; and  in  the  young 
of  large  birds  shows  beautifully  the  structure  of  the  uriniferous 
ducts  on  the  surface  of  the  gyri  and  lobules. 

The  kidneys  of  the  adult  bird  are  not  only  divided  into  several 
masses,  but  these  present  a surface  composed  of  innumerable  minute 
lobules.  These  lobules  arise  from  continuous  gyri  variously  ar- 
ranged ; the  margins  of  these  gyri  only  project,  whence  the  multi- 
form surface,  viewed  through  the  microscope,  seems  to  imitate  nearly 
the  gyri  of  the  convolutions  of  the  brain. 

The  kidneys  of  the  bird,  after  being  hatched,  require  no  injection 
to  demonstrate  the  disposition  of  the  uriniferous  ducts.  Being  na- 
turally filled  with  white  solid  urine  (urate  of  ammonia),  they  may 
be  observed  in  large  birds,  especially  ravens,  by  the  naked  eye,  in 
the  first,  second,  third,  and  fourth  day  after  hatching.  All  the 
uriniferous  ducts,  to  their  most  remote  pinnatifid  extremities,  are 
swelled  with  whitish-yellow  matter,  their  proper  secretion,  consist- 
ing of  uric  acid. 

It  is  difficult  to  convey  a distinct  and  correct  idea  of  the  arrange- 
ment now  described  without  figures.  But  it  may  appear  to  be 
compared  to  that  produced  by  a long  frill  or  ruffle  of  muslin  or 
cambric  which  is  doubled  up  and  folded  on  itself  six,  eight,  or  ten 
times,  with  the  frilled  edges  allowed  to  project,  and  all  within  an 
oval  or  elliptical  space  of  half  an  inch  or  less. 

By  micrometrical  measm’ement,  the  terminations  of  the  m'inife- 
rous  ducts  are  about  *00174,  that  is,  loselo  of  one  Paris  inch  in 
diameter.  This  is  much  larger  than  the  diameter  of  the  blood- 
vessels. Supposing  the  diameter  of  the  smallest  blood-vessels  to 

3 D 


786 


GENERAL  AND  EATHOLUGICAL  ANATOMY. 


be  0'00025,  or  ioIboo  of  one  Paris  inch,  then  they  are  seven  times 
smaller,  or  the  ducts  are  seven  times  larger. 

In  Mammalia,  the  following  are  the  most  important  facts  to  be  I 
known  in  the  development  and  structure  of  the  kidneys. 

In  the  embryo  of  Mammalia  as  well  as  of  Birds,  Wolffian  bo- 
dies are  observed  ; and  as  they  are  largest  in  the  earliest  period  of 
embryal  life,  they  have  by  Dzondi  and  others  been  mistaken  for 
kidneys.  They  consist,  as  in  birds,  of  very  slender  closed  intesti-  |i 
mda.  In  the  younger  embryos  they  are  larger  than  the  kidneys, 
and  then  chiefly  simulate  these  organs ; afterwards  they  are  con-  , 
founded  with  the  testicles,  being  lower  in  situation  and  of  the  same 
size  as  the  kidneys,  so  that  it  is  difficult  to  distinguish  between  the 
three  organs.  They  differ  from  the  kidneys  in  Mammalia  in  being 
covered  by  an  external  envelope,  on  removing  which  the  intestinula 
protrude,  arranged  transversely. 

The  kidneys  are  rounded.  In  the  sheep  they  present  vessels 
shooting  from  the  notch  or  umbilicus  (Jiilus)  towards  the  circumfe- 
rence in  bundles,  which  are  divaricated  in  arch-like  folds  and  retort- 
ed, yet  all  terminate  in  large  vesiculcB  pedunculated  and  hollowed. 

In  almost  all  embryos  of  Mammalia,  the  kidneys  consist  of  mul- 
tiplied lobules  in  which  the  same  arrangement  of  pedunculated  and 
closed  tubes  is  presented  and  repeated  in  various  forms.  In  some 
animals  this  multiplied  division  or  lobulated  form  of  the  kidney  is 
retained  through  life.  In  others,  certainly  the  greater  number, 
the  kidney  appears  in  the  shape  of  one  general  organ  ; but  this  is 
caused  merely  by  its  external  appearance,  or,  to  speak  more  accu- 
rately, by  the  arrangement  of  the  cortical  matter  outside.  In  the 
human  foetus  the  lobulated  arrangement  is  manifest,  and  is  in  cer- 
tain instances  continued  after  birtb ; but  in  most  instances  the  kid- 
ney appears  like  one  undivided  organ. 

This  difference  further  is  of  use  in  illustrating  the  anatomy  of 
glandular  organs  in  general.  The  lobulated  or  divided  state  is 
continued  thi’ough  life  in  certain  animals,  as  the  ox,  the  bear,  the 
badger,  and  several  of  the  cetacea,  especially  the  porpoise.  In 
these  animals  the  kidneys  consist  not  of  one  united  mass,  but  of  a 
number,  more  or  less  considerable,  of  separate  bodies,  each  pre- 
senting and  repeating  the  same  internal  structure. 

Thus  in  the  ox  the  kidney  consists  of  a series  of  sixteen  or  se-  i[ 

venteen  lobules  or  separate  parts,  each  of  which  presents  the  fol-  If 

lowing  arrangement  from  the  pelvis  or  common  excretory  cavity. 

4 


STRUCTURE  OF  INDIVIDUAL  GLANDS — THE  KIDNEY.  787 

First  is  a large  but  short  duct  or  canal  lined  by  a membrane  con- 
tinuous with  that  of  the  pelvis ; this  terminates  in  a shut  or  closed 
cavity  called  cup^  {calyx^  or  funnel  (infundibulum).  Into  this  cavity 
projects  a small  conical  eminence,  {papilla).,  with  an  aperture  in 
its  apex.  From  this,  urine  may  be  made  by  pressure  to  exude ; and 
when  the  papilla  is  divided  by  a longitudinal  section,  it  is  observed 
that  one  short  duct  from  which  the  urine  issues,  is  the  termination 
of  a great  number  of  small  capillary  tubes  which  are  disposed  lon- 
gitudinally, yet  radiating  or  converging  towards  the  small  papillary 
duct.  These  are  the  uriniferous  ducts  of  Bellini ; {tuhuli  Belliniani). 

At  these  upper  or  peripheral  ends  is  placed  a species  of  structure 
which  is  parenchymatous  and  granular  in  aspect  but  vascular  in 
arrangement,  that  is,  it  consists  mostly  of  blood-vessels  ramified  to 
an  infinite  degree  of  minuteness  and  delicacy.  On  the  mode  in 
which  these  vessels  are  arranged  at  their  terminations,  ‘Muller  states 
that  the  arteries  terminate  in  a very  minute  and  delicate  vascular 
or  capillary  network,  which  lies  between  the  closed  ends  of  these 
tubes,  and  that  from  this  network  again  veins  arise  as  in  other 
textures  of  the  body. 

The  papillary  cone,  which  is  about  half  an  inch  from  base  to 
apex,  and  rather  less  than  half  an  inch  at  base,  consists  of  firm 
solid  matter,  the  colour  of  which  is  white  or  pale  gray.  Its  exte- 
rior structure  is  formed  of  numerous  tubes  uniting  and  converging 
from  the  base  to  the  papilla  or  apex. 

Beyond  this  the  substance  of  the  tubular  part  is  of  a bright  pink 
colour,  less  firm,  but  more  distinctly  consisting  of  multiplied  tubes 
placed  close  to  each  other,  and  converging  from  the  base  to  the 
segment  of  the  frustum,  on  which  the  papillary  portion  rests. 

In  the  bear  and  badger,  these  separate  lobules  or  diminutive 
kidneys  are  still  more  numerous ; but  the  internal  arrangement  is 
quite  the  same. 

In  the  dolphin  and  porpoise  the  same  multiplied  division  is  car- 
ried to  a very  great  length.  The  masses  called  kidneys  in  these 
animals  consist  of  an  immense  number  of  tetrahedral,  trapezoidal, 
or  hexadral  small  bodies,  connected  to  each  other  by  cellular  tis- 
sue and  blood-vessels  not  very  firmly,  and  in  such  manner  that  they 
may  be  easily  separated.  The  number  of  these  renculi  it  is  difficult 
in  the  Cetacea  to  fix.  I am  sure  I have  numbered  more  than 
200,  yet  have  not  exhausted  them.  Each  renculus  presents  the 
internal  tubular  or  medullary  portion,  consisting  of  multiplied  tu- 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


bnles  placed  along  over  each  other,  and  the  external  cortical  or 
vascular  portion  consisting  of  blood-vessels  most  minutely  ramified, 

When  in  any  of  these  simple  or  integral  kidneys  the  aperture  of 
the  papilla  is  examined,  it  is  found  to  be  continued  into  a short 
thickish  tube  not  larger  than  one  line  or  one  line  and  a-half,  which 
then  is  divided  into  two  small  cylindrical  trunks.  These  again, 
after  a short  space,  are  divided  into  two  others  of  the  same  diameter 
almost,  very  different  from,  and  much  larger  than  blood-vessels. 
Thence  they  advance  dichotomous,  cylindrical,  straight,  or  deviat- 
ing little  from  the  straight  direction,  and  in  their  course  constantly 
double  and  multiply  themselves  to  the  base  of  the  papilla^  being 
conjoined  by  tender  cellular  substance.  When  increased  in  number, 
without  being  diminished  in  diameter,  they  are  collected  into  one 
or  two  bundles  separate  from  each  other  by  blood-vessels.  Each 
of  the  bundles  enters  then  its  own  meatus  formed  by  the  vascular 
plexus  of  the  vault  or  arch.  After  this,  the  small  ducts  contained 
in  their  respective  fasciculi,  and  connected  with  each  other,  are  no 
longer  dichotomous,  but  proceed  singly  in  the  same  direction 
through  the  substance  of  the  cortex,  whence  they  diverge  laterally, 
and  in  a serpentine  course,  contorted  in  numerous  convolutions,  and 
wandering  far  from  the  branches.  One  single  serpentine  duct, 
continued  from  the  straight  duct,  not  inserted  into  the  same,  de- 
ffected  laterally,  preserves  almost  always  the  same  diameter  and 
whiteness. 

These  uriniferous  ducts  further  are  continued  into  the  cortical 
part  of  the  kidney,  a fact  first  ascertained  by  Schumlansky,  and 
afterwards  by  Huschke,  by  injecting  them  under  the  receiver  of 
the  air-pump.  According  to  Schumlansky,  as  the  straight  ducts  or 
Bellinian  tubes  advance  to  the  pei’iphery  of  the  kidney  they  dimi- 
nish in  number,  or  rather  they  terminate  in  serpentine  ducts,  which, 
with  many  windings  and  convolutions,  proceed  between  the  few  and 
diminishing  straight  ducts  onwards  to  the  periphery  or  extreme 
edge  of  the  cortical  matter.  Before  the  straight  ducts  reach  this 
point  or  line,  all  of  them  have  terminated  in  serpentine  ducts  which 
communicate  by  multiplied  arches,  so  that  at  the  peripheral  edge  of 
the  cortical  matter  no  straight  ducts  exist. 

Not  essentially  different  is  the  account  given  by  Huschke.  Ac- 
cording to  his  account,  when  the  tubes  reach  the  utmost  limits  of 
the  medullary  matter  of  the  organ,  they  proceed  progressively,  se- 
parating from  each  other,  until  in  the  surface  of  the  kidney  they 


STRUCTURE  OF  INDIVIDUAL  GLANDS — MALPIGHIAN  BODIES.  789 


begin  to  wind  in  serpentine  directions,  forming  arches  with  each 
other,  and  again  turn  backwards  and  are  insensibly  lost,  becoming 
still  more  minute,  yet  without  entering  the  Malpighian  bodies. 

The  mention  of  these  objects  renders  it  necessary  to  explain  what 
they  are. 

Though  Eustachi  appears  to  have  maintained  the  existence  of  a 
sort  of  minute  glandular  grains  in  the  kidney,  Malpighi  was  the 
first  who  spoke  of  them  distinctly  and  confidently.  He  states  that 
in  all  the  kidneys  examined  by  him,  in  quadrupeds,  the  tortoise, 
and  in  man,  he  observed  a cluster  of  minute  glandules  by  the  fol- 
lowing means.  A black  fluid,  mixed  with  spirit  of  wine,  was  in- 
jected into  the  renal  artery,  so  as  to  cause  the  whole  kidney  to  be 
swelled  and  of  a black  colour  externally.  Then  on  stripping  off 
the  external  membrane,  there  appeared  attached  here  and  there  to 
the  dividing  arteries  small  glandules  stained  of  a black  colour ; and 
on  making  a longitudinal  section  of  the  kidney,  it  was  possible  to 
observe  between  the  bundles  of  the  urinary  vessels,  {i.  e.  the  ducts,) 
and  in  the  spaces  thereby  formed,  the  same  glands,  almost  without 
number,  attached  to  the  blood-vessels,  distended  with  the  black 
fluid,  like  apples  suspended  to  the  branches  of  a tree.^  He  after- 
wards adds  that  these  bodies  are  placed  in  the  utmost  region  of  the 
kidney  in  almost  countless  numbers ; that  he  thinks  it  likely  that 
they  correspond  to  the  urinary  vessels  of  which  the  mass  of  the 
kidneys  consists ; that  as  to  shape,  by  reason  of  their  minuteness 
and  remarkable  translucency,  though  they  cannot  be  said  to  be 
distinctly  circumscribed,  yet  they  appear  round  like  the  ova  of 
fishes ; they  are  blackened  when  a dark-coloured  fluid  is  injected  into 
the  arteries ; and  they  are  placed  among  the  extreme  branches  of  the 
arteries,  which  wind  round  them  like  tendrils,  so  that  they  appear 
surrounded  by  the  former,  with  this  exception,  however,  that  the 
portion  attached  to  the  arterial  branch  is  black,  while  the  rest  re- 
tains its  own  colour.f 

In  these  injections,  Malpighi  explicitly  states,  that  he  never  saw 
the  liquor  thrown  into  the  artery,  though  it  blackened  the  nearest 
portion,  get  into  the  urinary  ducts,  or  the  round  masses  which  he 
considered  as  the  glandules  of  the  kidney.  This  agrees  with  what 
is  long  afterwards  maintained  by  Muller. 

The  round  or  globular  bodies  thus  described  by  Malpighi  were 

* De  Renibus,  Caput  II.  apud  Opera  Omnia,  pag.  6'0.  Folio.  Londini,  1680'. 
t De  Renibus,  Cap.  III.  p.  92. 


790 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


seen  afterwards  by  Winslow,  Ferrein,  Schumlansky,*  Eysenhardt, 
Huscklie,  Muller,  Henle,  Bowman,  Gerlacb,  Bidder,  and  in  short 
all  those  who  have  studied  the  minute  anatomy  of  the  kidney.  They 
have  been  denominated  from  the  anatomist  who  first  directed  at- 
tention to  them  Corpora  Malpighiana.  \ 

At  the  same  time  it  must  be  observed,  that,  whether  from  some 
confusion  of  ideas,  or  from  presuming  that  these  bodies  must  be 
well  known,  almost  all  those  who  have  spoken  of  them  have  given 
them  different  names  at  different  times,  so  that  it  is  difficult  to  know 
whether  all  understood  the  same  objects.  Ruysch,  for  example, 
regards  these  round  or  globular  bodies  as  balls  of  the  extremities  of  ! 
blood-vessels  {glomeres  vasculorum)  convoluted  on  themselves,  and 
not  as  glands ; nor  does  he  allow  that  they  are  surrounded  by  any 
membrane.  Similar  opinions  were  entertained  by  Berger  and  Vieus-  t 
sens,  and  especially  Peyer,  who  contended  decidedly  for  their  being 
winding  and  contorted  vessels.  Schumlansky  long  afterwards  calls  i 
them  glandulcB  auctorum,  and  while  he  in  one  passage  represents  the 
clustering  terminations  of  the  arterial  capillaries  as  the  glandules  of 
Malpighi,  in  another  he  distinguishes  these  glandules  from  the  glo- 
meres  and  glomeruli^  or  vascular  balls  of  Ruysch.  This  anatomist, 
after  injecting  kidneys,  and  examining  them,  concludes  that,  though 
the  appearances  favour  at  once  the  doctrine  of  Malpighi  and  that  of 
Ruysch,  there  are,  amidst  the  blood-vessels  of  the  cortical  portion 
of  the  kidney,  granules  or  globular,  polyhedral  or  polymorphous 
bodies,  which  may  be  injected  from  the  arteries ; yet  he  doubts 
whether  these  are  hollow  like  follicles.  He  allows  that  they  are 
connected  by  cellular  tissue ; and  he  says  further,  that  they  are  the 
terminations  of  the  serpentine  uriniferous  ducts,  f 

According  to  Muller,  the  Malpighian  bodies  are  vesiculos^  or 
spherical,  or  spheroidal  bladders,  which  contain  glomeruli  or  glo- 
bular clusters  of  minute  blood-vessels,  and  which  may  be  extracted 
or  removed  from  the  vesicular  coverings.  He  thinks  also,  that 
another  matter  besides  these  blood-vessels  is  contained  in  the  vesi- 

* Arteriarum  rami  dant  vieissim  ramulos  laterales,  capillares,  brevissimos,  magis 
minus  copiosos,  quibus  tanquam  pedicillis  appenduntur  grana,  cuique  unum,  seminum 
papaveris  similia,  nunc  materie  turgida.  Totus  ramus  cum  suis  pedunculis  et  mole- 
culis  subrotundis  lustratus,  refert  fere  ribium  racemum.  En  famosas  glandulas  Mal- 
piGHii,  earumque  acinos.  D.  Alex.  Schumlansky  De  Structura  Renum  Tractatus  Phy- 
siologico-Anatomicus.  Edente  G.  C.  Wurtz,  M.  D.,  &c.  Cum  II.  Tabuhs  jEneis.  ' 
Argentorati,  1788.  8vo.  § xxix.  p.  77. 

f T).  Alex.  Schumlansky,  &c.  § xxxvii.,  xxxix.,  xl.,  et  xlii.  ■ 


STRUCTURE  OF  INDIVIDUAL  GLANDS — MALPIGHIAN  BODIES.  791 


culcB,  and  that  this  adheres  at  one  point  only.  When  these  glome- 
ruli or  spherical  balls  of  capillaries  are  extracted,  there  are  left 
smooth  hollow  hemispheres,  through  the  wall  of  which  blood-vessels 
adjacent  appear.  This  vesicula  forms  the  capsule  of  the  Malpighian 
bodies. 

The  diameter  of  a Malpighian  body,  at  an  average,  is  about 
Togo  of  000  Paris  inch.  The  blood-vessels  vary  in  diameter  from 
rgVoo  to  of  one  Paris  inch.  Consequently,  the  former  are 

from  thirteen  to  eighteen  times  larger  than  the  latter. 

Huschke  allows  that  the  Malpighian  bodies  are  filled  from  the 
arteries,  and  are  attached  to  these  vessels ; in  short,  that  they  are, 
as  Ruysch  maintained,  glomeruli  of  blood-vessels. 

Upon  the  whole,  the  Malpighian  bodies  may  be  described  as 
globular  or  ovoidal  vesicles,  situate  amidst  or  appended  to  the  mi- 
nute capillary  divisions  of  the  arteries,  which  are  curled  round  them 
as  tendrils  of  the  vine  or  hop-plant.  When  the  kidney  is  macerated 
in  water,  the  Malpighian  bodies  may  also  be  separately  distinguished, 
lying  in  all  directions  between  the  serpentine  uriniferous  ducts. 
There  they  resemble  vesicles,  according  to  Muller  ; and,  while  they 
are  attached  to  the  arteries,  there  is  no  communication  between  them 
and  the  urinary  ducts.* 

The  accuracy  of  this  last  statement  is  partly  controverted  by  Mr 
Bowman,  who  has  examined  these  bodies  with  much  care.  He  found 
them  to  be  a rounded  mass  of  minute  vessels  invested  by  a cyst  of 
similar  appearance  to  the  basement  membrane  of  the  tubes.  He 
ascertained  also  that  the  investing  capsule  is  the  basement  mem- 
brane of  the  uriniferous  tubes  expanded  over  the  tuft  of  blood-ves- 
sels. 

It  appears  further  that  the  terminal  twigs  of  the  artery  corre- 
spond in  number  with  the  Malpighian  bodies.  Arrived  at  them, 
the  twig  perforates  the  capsule,  and  dilating  suddenly  breaks  up 
into  two,  three,  four,  or  even  eight  branches,  which  diverge  in  all 
directions  like  petals  from  the  stalk  of  a flower,  and  usually  run, 
in  a more  or  less  tortuous  manner,  subdividing  again  once  or  twice 
as  they  advance,  over  the  surface  of  the  ball,  they  are  about  to 
form.  The  vessels  resulting  from  these  subdivisions  are  very  small, 
and  consist  of  one  simple,  homogeneous,  transparent  membrane. 
They  plunge  into  its  interior  at  different  points,  and  after  further 

* De  Glandularum  Secernentiuni  Structura  Penitiori.  Commentatio  Anatomica. 
Scripsit  Joannes  Mueller.  Lipsiae,  1830.  Folio. 


792 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


convolutions  reunite  in  one  single  small  vessel,  varying  in  size,  be- 
ing generally  smaller,  butjn  some  situations  larger,  than  the  ter- 
minal twig  of  the  artery.  This  vessel  emerges  between  two  of  the 
primary  divisions  of  the  terminal  twig  of  the  artery,  perforating 
the  capsule  close  to  that  vessel,  and,  like  it,  adhering  to  this  mem- 
brane in  its  transition.  It  then  enters  the  capillary  plexus  which 
surrounds  the  tortuous  uriniferous  tubes. 

The  tuft  of  vessels  thus  formed  is  a compact  ball,  the  parts  of 
which  are  held  together  by  their  mutual  interlacement ; there  be- 
ing no  other  tissue,  according  to  Mr  Bowman,  forming  the  capsule 
except  blood-vessels.  It  is  lobulated,  at  least  in  certain  animals, 
as  man  and  the  horse. 

The  basement  membrane  of  the  uriniferous  tube,  expanded  ovei’ 
the  Malpighian  body  so  as  to  form  its  capsule,  is  a simple,  homo- 
geneous, and  perfectly  transparent  membrane,  in  which  no  struc- 
ture can  be  recognized.  It  is  perforated,  as  before  stated,  by  the 
afferent  and  efferent  vessels,  and  not  reflected  over  them.  They 
are  united  to  it  at  the  point  of  transit.  Opposite  to  this  point  is 
the  orifice  of  the  tube,  the  cavity  of  which  is  continuous  with  that 
of  the  capsule,  generally  by  a contracted  neck.  This  continuity 
Mr  Bowman  observed  in  mammalia,  birds,  reptiles,  and  fishes. 
When  a thin  section  of  a Malpighian  body  parallel  to  the  neck  of 
the  tube  is  made,  the  capsule  is  observed  to  pass  off  into  the  base- 
ment membrane  of  the  tube,  as  the  body  of  a Florence  flask  into  its 
neck.  The  basement  membrane  of  the  tube  is  lined  by  a nucleated 
epithelium  of  fine-granular  opaque  aspect ; while  the  neck  of  the 
tube  and  its  orifice  are  abruptly  covered  with  a layer  of  cells  much 
more  transparent,  and  clothed  with  vibratile  cilia.  Within  the 
capsule  these  cilia  cease ; and  the  epithelium  beyond  is  very  deli- 
cate and  translucent.  The  cavity  existing  in  the  natural  state  be- 
tween tbe  epithelium  and  the  tuft,  is  filled  with  fluid  in  which  the 
vessels  are  bathed,  and  which  is  continually  impelled  onwards  by 
the  movement  of  the  cilia. 

The  tubules  on  quitting  the  Malpighian  bodies  become  greatly 
contorted ; and  this,  Mr  Bowman  infers,  is  their  constant  disposi- 
tion. The  tortuous  tubes  unite  again  and  again  in  twos,  and 
in  their  course  centrad  become  straight,  forming  the  pyramids  of 
Ferrein,  and  the  medullary  cones  of  Malpighi.  Among  these  con- 
volutions the  Malpighian  bodies  are  imbedded,  and  are  in  contact 
on  all  sides  with  the  surrounding  tubes. 


r( 


STRUCTURE  OF  INDIVIDUAL  GLANDS — ^SIALPIGHIAN  BODIES.  793 


The  blood  leaving  the  Malpighian  bodies  is  conveyed  by  their 
efferent  vessels  to  the  capillary  plexus  surrounding  the  uriniferous 
tubes.  The  vessels  of  this  plexus  lie  in  the  interstices  of  the  tubes, 
anastomosing  everywhere  freely,  and  forming  one  continuous  net- 
work lying  outside  the  tubes,  in  contact  with  the  basement  mem- 
brane. This  capillary  plexus  is  interposed  between  the  efferent 
vessels  of  the  Malpighian  bodies  and  the  veins. 

The  efferent  vessels  of  the  Malpighian  bodies  never  inosculate 
with  each  other,  each  being  an  isolated  channel  between  its  Mal- 
pighian tuft  and  the  plexus  surrounding  the  tubes.  They  are 
formed  by  the  union  of  the  capillary  vessels  of  the  tuft,  and,  after 
a course  variable  in  length,  they  open  into  the  plexus.  They  vary 
in  size.  In  general  they  are  smaller  than  the  terminal  twig  of  the 
artery,  and  scarce  larger  than  the  vessels  of  the  plexus  into  which 
they  empty  their  contents.  They  are  larger  in  large  Malpighian  tufts. 

From  the  plexus  now  mentioned,  the  veins  arise  and  form  the 
set  of  venous  plexus,  situate  in  the  nipple-shaped  extremities  of  the 
cones,  round  the  orifices  of  the  tubes,  and  pursuing  a retrograde 
course  to  empty  their  contents  into  veins  situate  at  the  base  of  the 
cones.  Another  set  of  venous  radiculse  are  dispersed  through 
the  cortical  part  of  the  kidney,  and  each  receives  blood  on  all  sides 
from  the  plexus  surrounding  the  convoluted  tubes. 

From  tbe  account  now  given  of  the  arrangement  of  the  vessels 
connected  with  the  Malpighian  bodies,  hlr  Bowman  infers  that  in 
the  kidney  there  are  two  ■perfectly  distinct  systems  of  capillary  ves- 
sels, through  both  of  which  the  blood  in  its  course  from  the  arteries 
into  the  veins  passes.  The  first  is  that  system  of  vessels  proceeding 
immediately  from  the  arteries,  and  inserted  into  the  dilated  extre- 
mities of  the  uriniferous  tubes,  (the  Malpighian  bodies,)  the  Mal- 
pighian capillary  system  ; the  second  that  enveloping  the  convolu- 
tions of  the  tubes,  and  communicating  directly  with  the  veins. 
The  efferent  vessels  of  the  Malpighian  bodies,  which  convey  the 
blood  between  these  two  systems,  Mr  Bowman  regards  as  perform- 
ing to  the  kidney  the  same  function  which  the  portal  veins  per- 
form to  the  liver,  and  these  he  accordingly  regards  as  collected 
in  the  portal  system  of  the  kidney.  The  only  difference  is  the  ab- 
sence of  one  general  single  portal  trunk. 

In  short,  Mr  Bowman  thinks  that  he  has  established  the  follow- 
ing facts. 

15^,  That  each  Mal])ighian  body  consists  of  the  dilated  extremity 


794  GENERAL  AND  PATHOLOGICAL  ANATOMY. 


of  a uriniferous  tube,  with  a small  mass  of  blood-vessels  inserted 
into  it. 

2(i,  That  the  Malpighian  bodies  may  be  easily  injected  from  the 
arteries,  and  that  the  capillaries  surrounding  the  uriniferous  tubes 
may  be  injected  though  less  easily.  When  the  tubes  are  injected, 
it  is  by  extravasation  from  the  Malpighian  tufts. 

2)d,  By  the  veins,  the  capillaries  surrounding  the  tubes  may  be 
injected  ; but  neither  the  Malpighian  bodies,  nor  the  arteries,  nor, 
without  extravasation,  the  tubes.  The  main  cause  of  this  impediment 
to  injection  and  the  movement  of  fluids  from  the  veins  into  the  ar- 
teries is  the  position  and  small  size  of  the  efferent  vessels  of  the 
Malpighian  bodies,  which  stand  in  the  way  of  any  fluids  being 
transmitted  to  the  Malpighian  vessels. 

4#^,  The  Malpighian  bodies  cannot  be  injected  from  the  tubes, 
neither  can  the  plexus  surrounding  the  tubes  or  the  veins  be  in- 
jected without  extravasation. 

5th,  There  is  only  one  Malpighian  body  to  each  serpentine  tube. 

Qth,  The  epithelium  of  the  tube,  when  it  enters  the  expanded  por- 
tion which  forms  the  Malpighian  body,  becomes  transparent,  and  is 
covered  with  vibrating  cilia.*  Within  the  capsule,  however,  of  the 
Malpighian  body,  the  cilia  cease. 

The  accuracy  of  several  of  the  representations  of  Mr  Bowman 
has  been  doubted,  and  more  or  less  decidedly  controverted  by 
Huschke,  Reichert,  Gerlach,  and  Bidder.  Reichert  states,  that 
whatever  means  be  adopted,  by  making  minute  sections  of  recent 
kidneys,  and  using  high  magnifying  powers,  he  never  was  able  to 
observe  any  transition  of  the  uriniferous  ducts  into  the  capsule  of 
the  Malpighian  bodies.! 

On  the  other  band,  some  confirmation  of  the  correctness  of  this 
part  of  Mr  Bowman’s  representation  is  furnished  by  the  structure 
of  the  kidney  in  the  Myxinoid  fishes  by  Muller.  In  these  animals, 
which  present  the  simplest  type  of  renal  structure,  this  connection 
is  undoubted. 

Gerlach  made  trials  of  the  same  kind  as  those  by  Reichert,  yet 
without  tracing  any  connection  between  the  uriniferous  tubes  and 

* On  the  Structure  and  Use  of  the  Malpighian  Bodies  of  the  Kidney,  with  Obser- 
vations on  the  Circulation  through  that  Gland.  By  W.  Bowman,  F.R.S.,  &c.  Read 
February  17,  1842.  Philosophical  Transactions  of  the  Royal  Society  of  London  for 
1842.  London,  1843.  Part  i.  p.  57. 

t Bericht  iiber  die  Fortschritte  der  Microscopischen  Anatomiein  dem  Jahre  1842.  j 
Von  Reichert,  Prof,  in  Dorpat.  in  Muller’s  Archiv,  Jahrgang  1843.  ' 


STRUCTURE  OE  INDIVIDUAL  GLANDS — MALPIGHIAN  BODIES.  795 


the  capsule.  He  further  denies  that  the  uriniferous  ducts  terminate 
in  shut  ends  in  the  capsule.  These  ducts  or  tubules  form  collars, 
and  what  has  been  taken  for  shut  ends  of  ducts,  are  nothing  but 
the  capsules,  which  communicate  with  the  same  by  means  of  a short 
neck,  which  is  evidently  thinner  than  the  uriniferous  duct.  The 
capsule  is  not  a blind  termination  of  a uriniferous  duct,  but  a re- 
traction or  introversion, — a diverticulum  of  the  same  structureless 
membrane  which  forms  the  uriniferous  tubes. 

Gerlach  admits  that  the  account  given  by  Mr  Bowman  of  the 
perforation  of  the  capsule  by  the  arteries  is  correct. 

As  to  the  point  at  which  the  capsule  is  perforated  by  tbe  affer- 
ent and  efferent  vessels,  Gerlach  thinks  that  the  statement  of  Mr 
Bowman  is  too  exclusive,  when  he  represents  this  point  to  be  al- 
ways opposite  to  the  opening  of  the  uriniferous  tube  into  the  capsule. 
He  gives  a figure,  (fig.  12,)  which  shows  that  the  point,  at  which 
the  afferent  and  efferent  vessels  perforate  the  capsule  does  not 
always  correspond  to  the  point  of  communication  between  tbe  uri- 
niferous ducts  and  tbe  capsule. 

The  point  in  Mr  Bowman’s  statements,  which  has  been  most 
strongly  controverted  both  by  Reicher  and  Huscbke,  is  that  as 
to  the  free  entrance  of  the  Malpighian  capillary  net-work  into 
the  cavity  of  the  capsule  ; and  both  justly  remark  that  such  an  as- 
sumption is  at  variance  with  all  experience  hitherto  collected  on 
the  laws  of  histological  organization ; there  being  no  example  yet 
known  of  vessels  lying  immediately  in  the  cavity  of  a secreting  tis- 
sue. In  truth,  the  representation  of  Mr  Bowman,  that  the  water 
of  the  urine  is  separated  from  the  blood  flowing  in  the  Malpighian 
capillary  vessels  by  simple  transudation  alone,  while  the  peculiar 
constituents  of  the  urine  are  separated  through  cells  at  the  inner 
surface  of  the  uriniferous  ducts,  Gerlach  regards  as  in  every  respect 
a rash  statement,  and  to  be  corroborated  by  no  other  fact.  On  the 
other  hand,  all  investigations  on  glands  prove,  that  in  the  process 
of  secretion,  cells  are  the  essential  element ; and  in  the  present 
state  of  science,  it  is  impossible  to  think  of  secretion  without 
cells. 

He  further  adds,  that  wRen  the  Malpighian  capillary  net-work 
is  closely  examined,  after  the  capsule  has  been  entirely  detached 
from  it,  we  see  it  in  its  whole  extent  covered  by  a thick  layer  of  nu- 
cleated cells,  which  are  continued  from  the  inner  wall  of  the  capsule 
upon  the  Malpighian  vessels ; and  the  latter  lies  introverted  within  a 


796 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


layer  of  cells,  like  the  intestine  within  the  peritonaeum.  The  Mal- 
pighian capillary  net-work  further  possesses  the  essential  element 
of  secretion,  in  which  the  blood  undergoes  those  chemical  changes, 
which  the  metabolic  force  of  the  gland-cells  imparts  to  the  secreted 
product.  The  secretion  in  the  Malpighian  vessels  differs  from  the 
usual  secretions,  only  in  so  far  as  between  vessels  and  secreting 
cells  there  is  no  structureless  membrane ; which  last,  however,  ap- 
pears not  to  be  an  essential  condition  to  the  process  of  secretion. 

On  the  existence  of  ciliary  motions  at  the  point  of  transition  of 
the  uriniferous  tubes  to  the  capsule,  evidence  is  contradictory. 
Huschke  and  Keichert  could  observe  no  ciliary  motion  in  the  places 
indicated  by  Mr  Bowman  ; and  the  latter  denies  even  any  layer  of 
cells  at  the  inner  surface  of  the  capsule.  On  the  other  hand,  Bis- 
choff  is  convinced  of  the  presence  of  cilia  in  the  kidneys  of  the  frog. 
Valentin  observed  ciliary  motions  not  only  in  the  spots  indicated  by 
Mr  Bowman,  but  even  within  the  capsule  ; and  Pappenheim  gave  a 
verbal  communication  on  the^ame  fact.  The  result  of  the  inquiries 
of  Gerlach  is  as  follows.  In  mammalia  he  could  never,  unless  he 
examined  perfectly  recent  kidneys,  observe  ciliary  motions  either  at 
the  cervix  or  in  the  capsule.  On  the  other  hand,  he  found  the  inner 
wall  of  the  capsule  lined  with  a very  slender  layer  of  cells,  which 
is  seen  very  distinctly  at  the  edge  of  the  capsule.  Between  these 
cells  lining  the  inner  wall  of  the  capsule  and  those  which  cover  the 
Malpighian  net-work,  normally  there  is  found  a small  interval. 

In  examining  the  recent  kidneys  of  the  frog,  on  the  other  hand, 
Gerlach  convinced  himself  of  the  presence  of  ciliary  motions  not 
only  in  the  cervix  or  collar,  but  also  in  the  whole  inner  surface  of 
the  capsule ; and  he  thinks  it  probable  that  ciliary  motion  is  a phe- 
nomenon not  peculiar  to  the  renal  capsule  of  the  frog,  but  gene- 
rally diffused  over  the  animal  kingdom.* 

The  results  obtained  by  Bidder  are  not  less  at  variance  with 
those  given  by  Mr  Bowman. 

Bidder  states,  first,  that  in  no  circumstances,  and  by  no  means 
which  he  could  devise,  could  he  obtain  any  certain  evidence  of  con- 
nection of  the  glomeruli  with  the  uriniferous  ducts.  The  vascular 
bundles  were  always  found  below  and  between  the  uriniferous  ducts, 
without  interior  relation  to  themselves,  either  uncovered  or  sur- 

* Bcitrage  ;jiu'  Stnikturlehre  der  Niere  von  Dr  Joseph  Gerlach,  prakt.  Aerzte  in 
Mainz.  Archiv  fur  Anatoniie,  Physiologic,  uud  Wissenschaftliche  Medicin,  von  Dr 
Johannes  Muller.  1845,  No.  IV.  Seite  878.  / 


STRUCTURE  OF  INDIVIDUAL  GLANDS — MALPIGHIAN  BODIES.  797 


rounded  by  the  capsule  seen  by  Muller.  Never  is  there  seen  on 
the  glomerulus  an  unequivocal  trace  of  an  aj)pended  canal,  and 
never  at  the  inner  surface  of  the  capsule,  or  any  where  else  in  the 
uriniferous  ducts,  ciliary  epithelium.  From  these  facts,  Bidder 
thinks  it  results,  that  the  representations  by  Mr  Bowman  contain 
one  fact  which  is  incorrect.  This  is,  that  as  stated  by  Gerlach,  the 
circumstance  of  vessels  being  exposed  uncovered  is  quite  at  va- 
riance with  all  hitherto  known  as  to  the  laws  of  organization.  He 
finds,  however,  from  examining  the  kidneys  of  the  water  salamander, 
that  while  the  representation  of  phenomena,  as  seen  by  Mr  Bow- 
man, is  essentially  correct,  the  explanation  of  these  phenomena 
requires  in  many  parts  to  be  rectified. 

For  the  investigation  in  question,  the  anterior  part  of  the  kidney 
of  the  male  triton,  ( Triton  taeniatus,)  is  particularly  well  adapted, 
because  it  is  by  nature  expanded  in  such  manner,  that  for  mi- 
croscopical examination  no  further  artificial  preparation  is  required. 
Indeed,  if  one  of  the  leaf-like  masses  of  serpentine  canals,  of  which 
the  part  of  the  kidney  specified  consists,  is  simply  cut  out  and 
placed  under  the  microscope,  this  is  all  that  is  requisite  in  order 
to  exhibit  completely,  without  exception,  the  whole  of  the  texture 
under  consideration.  Bidder  further  found  that  any  attempt  to 
improve  such  a preparation  by  artificial  means,  as  pulling  and  tear- 
ing with  needles,  to  expand  fully  the  convoluted  ducts,  usually 
obliterates  the  characteristic  texture,  removes  the  connectio’n  of  the 
glomeruli  with  the  uriniferous  ducts,  destroys  the  flask-like  dilated 
terminations  of  the  latter,  removes  the  aspect  of  ciliary  epithelium, 
and  otherwise  renders  the  part  unfit  for  examination,  so  as  to  give 
correct  results. 

In  the  fact  now  stated  lies  the  explanation  of  the  negative  re- 
sults always  obtained  from  examining  tbe  kidneys  of  the  frog,  be- 
cause the  microscope  cannot  be  employed  until  fine  sections  of  the 
renal  substance  have  been  spread  out  by  mechanical  means.  He 
allows,  also,  that  as  these  parts  are  not  so  easily  found  in  the  fi’og, 
it  is  no  small  proof  of  the  perseverance  of  Mr  Bowman,  and  the 
solidity  of  his  inquiries,  that  notwithstanding  these  unfavourable 
circumstances  in  the  higher  animals,  he  has  been  able  correctly  to 
give  the  essential  circumstances  of  the  renal  structure.  In  the  ser- 
pent family  and  in  lizards,  the  connection  of  the  glomeruli  with  the 
uriniferous  tubes  is  seen  with  comparative  ease.  But  never  in  the 
higher  animals  did  Bidder  find,  notwithstanding  numerous  trials, 


798 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


any  fact  which  could  suggest  or  establish  the  direct  connection  of 
these  parts  of  the  kidneys. 

In  the  triton,  on  the  other  hand,  there  are  observed  in  the  parts 
of  the  kidney  specified,  at  pretty  regular  distances  from  each  other, 
shut  terminations  of  the  uriniferous  tubes,  which  become  dilated  in 
the  flask-like  shape,  and  make  themselves  distinguished  from  the  cy- 
lindrical tubes  by  greater  transparency.  Before  the  transition  into 
these  dilated  parts,  the  uriniferous  tube  appears  to  he  sometimes 
contracted  ; yet  this  is  by  no  means  uniform.  Normally  only  one 
uriniferous  tube  passes  into  this  sort  of  dilated  portion  ; sometimes, 
however,  two  uriniferous  tubes  are  connected  with  the  same  dilated 
portion,  by  which  the  objection  of  an  illusion  taking  place  thereby 
is  completely  set  aside,  viz.  that  by  pressure  the  contents  of  one 
canal  may  be  forced,  without  impediment,  through  the  dilated  por- 
tion into  the  second  canal,  and  impelled  onwards  in  it.  In  such 
circumstances  also,  the  designation  may  he,  instead  of  a closed  ter- 
mination of  the  uriniferous  tube,  rather  a general  dilatation  in  the 
course  of  such  a tube. 

Of  the  presence  of  an  epithelium  with  actively  vibrating  cilia^ 
immediately  before  the  transition  of  the  uriniferous  tube  into  the"' 
flask-shaped  expansion,  and  in  the  cervix  or  collar  of  the  latter,  as 
also  in  a considerable  space  of  the  inner  wall  of  the  same.  Bidder 
states  that  he  has  completely  convinced  himself.  The  representa- 
tion of  Mr  Bowman,  that  the  vibratory  epithelium  layer  of  the  uri- 
niferous canals  is  prolonged  into  the  expanded  portion,  progres- 
sively diminishing  in  thickness,  he  finds  to  be  quite  correct ; but 
he  observes,  that  not  in  every  instance  can  we  expect,  even  in  the 
triton,  to  be  able  to  recognise  this  circumstance  with  the  desired  / 
certainty.  He  had  inspected  many  preparations  before  he  was  able 
for  the  first  time  to  be  satisfied  of  the  accuracy  of  the  observation 
of  Mr  Bowman.  The  third  part,  or  even  the  half  of  the  circum- 
ference of  the  flask-shaped  expansion  presents  this  ciliated  epithe- 
lium. If  the  same  appears  sometimes  to  be  still  more  expanded, 
this  depends  only  on  the  circumstance,  that  higher  up  detached  ci- 
liated cells  are  thrust  deeper  into  the  cavity. 

On  the  other  hand,  the  statement  which  Mr  Bowman  makes  in 
denying  any  epithelium  to  the  rest  of  the  walls  of  the  cavity.  Bid- 
der finds  to  be  inaccurate.  He  finds  here  a simple  thin  plate-form- 
ed epithelium,  which  appears  in  pretty  regular  polygonal  forms ; 
and  if  this  do  not  appear  equally  evident  in  every  case,  the  defi- 


4 


STRUCTURE  OF  INDIVIDUAL  GLANDS — MALPIGHIAN  BODIES.  799 


ciency  appears  to  depend  on  this  circumstance,  that  from  the  con- 
tiguous uriniferous  tubes  entire  epithelium  cells  or  their  fragments 
are  thrust  by  the  pressure  of  the  covering  glass  plates  into  the  ca- 
vity, and  the  correct  view  in  the  same  is  destroyed.  The  original 
transparency  of  these  cells  is  frequently  lost  before  the  eyes  of  the 
observer ; and  there  is  thus  sufficient  opportunity  to  observe  imme- 
diately the  cause  here  specified. 

Opposite  the  entrance-spot  of  the  uriniferous  tube  into  that  ex- 
pansion, or  on  one  side  of  the  latter  when  it  is  connected  with  two 
tubes,  the  Malpighian  vascular  tuft  enters  the  uriniferous  tube, 
and  advances  to  a greater  or  less  depth  in  the  expanded  portion 
itself ; so  that  sometimes  it  fills  the  half  of  the  cavity,  sometimes 
it  occupies  a much  smaller  part  of  it.  As  to  the  statement  that 
the  glomerulus  perforates  the  wall  of  the  uriniferous  tube,  lies  un- 
covered and  free  in  this  cavity,  and  is  immersed  in  the  fiuid  of  the 
same,  it  must  be  indeed  admitted,  that  the  microscopical  image  on 
superficial  examination  appears  frequently  to  agree  with  this ; but 
that  this  is  nothing  but  an  illusive  appearance  any  one,  by  more 
careful  examination  of  all  the  circumstances  taking  place,  may  be 
convinced  in  the  most  positive  manner.  F or,  when  the  preparation 
has  not  lost  its  original  translucency  by  the  causes  mentioned,  it 
is  at  once  easy  to  observe,  sometimes  directly,  a partition  separating 
the  cavity  of  the  expanded  uriniferous  tube  from  the  vascular 
bundle.  This  partition  appears  like  a fine  arch-shaped  border  de- 
noted by  one  single  line,  the  convexity  of  which  is  directed  towards 
the  cavity,  and  the  concavity  towards  the  vascular  bundle,  which 
is  usually  most  difficult  to  be  distinguished  on  the  most  prominent 
points  of  the  vascular  network,  and  is  most  manifest  in  the  distri- 
butions on  the  delicate  interstices  of  the  same,  the  periphery  of  which 
is  in  uninterrupted  connection  with  the  proper  tunic  or  basement 
membrane  of  the  uriniferous  tubes.  But  even  if  this  partition  did 
not  present  itself  to  the  eye  with  the  desired  distinctness,  which 
from  its  delicacy  cannot  be  wonderful,  several  convincing  circum- 
stances indicate  its  presence. 

Isf,  The  already  mentioned  entrance  of  the  epithelial  fragments 
in  the  expanded  portions;  for,  while  the  latter  thereby  lose  their 
translucency,  that  of  the  Malpighian  bodies  is  little  or  not  at 
all  impaired,  and  remain  clear  and  transparent,  while  the  resi- 
dual blood  globules  or  their  nuclei  are  from  the  first  not  in  any 
way  diminished  in  transparency. 


800 


CxENERAL  AND  PATHOLOGICAL  ANATOMY. 


2d,  The  phenomena  of  compression  of  the  prepai’ation  prove  the 
existence  of  such  a partition.  The  fluid  granular  content  of  the  ex- 
panded portions  is  thus  impelled  hither  and  thither  without  any 
entrance  of  the  same  ever  being  effected  between  network  of  the 
vascular  bundle,  and  any  mutual  yielding  of  the  last ; and  by  such 
pressure  the  glomerulus  itself,  yet  always  only  in  one  mass,  and  not 
in  individual  vascular  clusters.  This  proves  unequivocally  the 
presence  of  a medium,  by  which  the  network  of  the  vascular  mass 
is  held  together ; and  that  this  connecting  bond  must  be  a mem- 
brane enclosing  the  whole  vascular  bundle,  and  cannot  be  a cement 
holding  one  of  the  separate  networks  to  another,  is  shown  by  this 
circumstance,  that  after  drawing  the  glomerulus  from  the  urinife- 
rous  tubes,  the  vascular  convolutions  drop  from  each  other,  and 
present  at  the  circumference  of  the  mass  disproportionately  larger 
furrows  than  in  the  natural  disposition  of  these  parts. 

Lastly,  by  continued  pressure  the  glomerulus  is  forced  back  from 
the  uriniferous  tubes,  nay,  may  be  expelled  from  them  entirely ; and 
in  such  circumstances  it  may  be  again  evidently  perceived,  that  the 
whole  flask-shaped  expansion  is  surrounded  by  one  uninterrupted 
outline,  on  the  outside  of  which  the  glomerulus  is  placed. 

Assuredly  the  uncovered  disposition  of  the  glomerulus  in  the  ca- 
vity of  the  uriniferous  tube  would  be  contradicted,  were  it  possible 
to  prove  that  the  plate-formed  epithelium,  which,  as  observed,  covers 
part  -of  the  cavity,  covers  also  the  vascular  mass.  Though  he  al- 
lows that  he  cannot  prove  this  unequivocally,  yet  he  maintains  that 
the  rectiflcation  here  suggested  is  probable.  This  he  does  in  the 
following  manner. 

The  relation  of  the  glomerulus  to  the  expanded  portion  of  the 
uriniferous  canal  appears  to  him  most  properly  to  be  referable  to 
the  series  of  those  formations  which  it  is  usual  to  designate  as  intro- 
versions ; by  which  nothing  is  stated  as  to  their  origin,  but  merely 
a certain  form  and  kind  of  position  of  organic  structures  within 
each  other  is  meant.  In  the  case  here  treated,  of  such  introver- 
sions, the  same  appears  to  take  place  at  the  thinnest  and  feeble&t 
point  of  the  wall  of  the  shut  end  of  the  uriniferous  tube.  This  is 
proved  by  the  fact,  that  when,  in  consequence  of  strong  pressure,  the 
expanded  portion  bursts,  this  bursting  regularly  happens  at  the 
point  where  the  proper  tunic  (basement  membrane)  of  the  urinife- 
rous duct  coalesces  with  the  glovxerulus.  The  outline  of  the  partition 
mentioned  appears  also  unequally  feebler  than  at  the  other  points 


STRUCTURE  OF  INDIVIDUAL  GLANDS — MALPIGHIAN  BODIES.  801 


of  the  circumference  of  the  expanded  portion.  But  this  undoubt- 
edly has  great  influence,  that  the  ligamentous  substance  which  lies 
on  the  outside  of  the  uriniferous  tubes  and  strengthens  their  walls, 
passes  in  uninterrupted  succession,  usually  upon  the  vessels  going 
to  the  glomerulus,  but  never  enters  the  glomerulus  itself,  so  that  the 
vascular  net-work  of  the  same  is  actually  held  together  only  by  the 
enclosing  slender  proper  tunic  of  the  uriniferous  ducts. 

In  Mr  Bowman’s  representation  of  the  renal  texture,  a misconcep- 
tion has  accordingly  happened  by  this,  that  the  capsule  of  the  glo- 
merulus and  the  expanded  portion  of  the  uriniferous  duct  are  fully 
identified,  while  both  are  to  be  easily  distinguished,  though,  as  be- 
longing to  one  and  the  same  organic  part,  they  pass  insensibly  into 
each  other.  In  the  agreement  in  the  anatomical  basement  of  the 
tunica  propria  of  the  uriniferous  ducts  and  the  capsule  of  the  glo- 
merulus, it  is  intelligible,  that  if  the  glomerulus  and  uriniferous  ducts 
are  separate  from  each  other,  in  the  first  no  trace  of  the  early  con- 
nection may  be  found,  while  the  only  available  means  thereto,  viz.  the 
position  relation  of  both,  are  removed.  So  it  is  intelligible,  how  the 
glomerulus,  after  artificial  spreading  out  sections  of  kidney  and 
detachment  from  the  uriniferous  ducts,  sometimes  lies  free,  some- 
times appears  surrounded  by  a capsule.  Because  this  capsule  is 
not  the  covering  belonging  originally  to  the  glomerulus,  but  only 
touches  at  the  neighbouring  connecting  tissue,  which,  after  sepa- 
rating the  glomerulus  from  the  uriniferous  ducts,  sometimes  sur- 
rounds the  same.  Hence  proceeds  the  statement  made  under  these 
circumstances,  that  the  glomerulus  lies  free  within  its  capsule.  In- 
deed there  is  here  between  the  vascular  packet,  the  net-work  of 
which  is  more  expanded,  and  the  connecting  tissue  accidentally 
lying  on  the  same,  a free  space  ; while  the  natural  capsule  of  the 
glomerulus,  that  is,  the  introverted  part  of  the  uriniferous  duct,  lies 
close  to  the  same. 

The  term  capsule  of  the  glomerulus  has  also  been  applied,  on  the 
one  hand,  to  the  flask-shaped  dilated  uriniferous  duct  itself,  because 
it  is  supposed  that  the  glomerulus  lies  free  in  the  same ; and,  on 
the  other  hand,  the  connecting  substance  surrounding  the  glome- 
rulus after  preparation  of  sections  of  renal  tissue  might  be  view- 
ed as  the  natural  capsule ; in  both  cases  the  true  capsule  would  be 
misunderstood.* 

■ Ueber  die  Malpighischen  Korper  der  Niere  ; von  F.  Bidder  in  Dorpat,  Archiv 
fur  Anatomie,  Physiologie,  und  Wissensehaftlichen  Medicin,  Von  Dr  Johannes  Mul- 
ler.  1845.  Heft  V.  Seite  508. 

3 E 


802 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Lastly,  A.  Kiilliker  of  Zurich  maintains  with  Mr  Bowman  not 
only  the  connection  of  the  renal  ducts  with  the  capsule  of  the  Mal- 
pighian bodies,  but  also  at  the  entrance  of  the  capsule  and  the  con- 
tiguous portions  of  the  renal  ducts,  or  in  the  neck  and  orifice  of 
the  uriniferous  tube,  the  existence  of  a ciliated  epithelium  with 
vigorous  acting  cilia. 

According  to  this  observer,  whose  observations  were  made  on 
the  kidneys  of  the  embryo  lizard,  uriniferous  ducts,  measuring  from 
Tofl  to  -,55  in  diameter,  consist  of  two  layers.  The  outer  is  formed 
of  a slender  structureless  membrane,  which  is  easily  distinguished 
by  the  addition  of  water,  and  is  altogether  a repetition  of  the  outer 
coat  of  the  renal  ducts.  The  inner  is  a stratified  epithelium,  from 
10^0  0 to  ^o5o  parts  of  one  inch  thick.  The  cells  of  which  it  con- 
sists are  roundish,  flat,  ]|sob  of  one  inch  thick,  broad,  with  * 
nuclei  in  two,  three,  or  more  layers  arranged  over  each  other. 
The  inner  layer  is  remarkable  for  distinctly  developed  ciliary  pro- 
cesses, from  io®oo  to  fSBo  of  one  inch  long,  which,  by  their  vigo-  ' 
rous  action,  attract  the  attention  of  the  most  superficial  observer, 
and  furnish  an  interesting  sight  in  transverse  sections  of  the  canal. 
The  ciliated  epithelium,  so  far  as  Kblliker  saw,  covers  the  whole 
length  of  the  canal  ; but  it  is  wanting  in  the  common  excretory 
duct  of  the  gland,  and  in  the  ends  of  the  canals.  These  are  the 
Malpighian  bodies,  the  existence  of  which,  in  the  primordial  renal 
matter,  has  been  established  by  Rathke’s  observations  on  the  de- 
velopment of  the  viper.  Every  Malpighian  body  which  has  a dia- 
meter of  from  150  fo  iSo  of  one  inch,  is  a bladder  or  vesicula, 
which  is  placed  immediately  at  the  end  of  the  renal  duct,  and  is  in 
free  communication  with  the  same.  The  structureless  membrane  | 
of  the  ducts  is  peculiar  to  it ; so  also  is  the  epithelium,  only  more 
slender,  and  is  formed  of  one  single  layer,  and  is  void  of  cilia. 
Within  the  Malpighian  body  is  a cluster  of  capillary  vessels,  which  , 
enter  and  emerge  at  the  origin  of  opposite  sides  of  the  canal,  and*, 
as  it  appears,  are  separated  from  the  cavity  of  the  renal  duct  or 
tubule  by  a layer  of  cells.* 

M.  Kolliker  further  thinks  that  it  may  be  owing  to  the  mode  of  ' 
preparing  the  parts,  that  Reichert  and  Bidder  did  not  observe  the  ^ 
ciliary  motions.  If  these  parts  are  copiously  sprinkled  with  water, 

t 

* It  does  not  very  clearly  appear,  from  this  mode  of  expression,  vhether  M.  Kol- 
liker describes  this  partition  from  his  omi  observation  or  from  that  of  Bidder,  by 
whom  I have  shown  this  partition  was  discovered. 


STRUCTURE  OF  INDIVIDUAL  GLANDS — MALPIGHIAN  BODIES.  803 


the  nucleated  cells  swell  so  much,  that  it  is  impossible  to  distin- 
guish the  nucleus  and  contents ; and  they  appear  only  as  pale,  ap 
parently  homogeneous  transparent  globules.  This  renders  the 
ciliated  movements  indistinct,  or  annihilates  them.  But,  at  all 
events,  M.  Kolliker  has  more  frequently  seen  them  in  preparations 
moistened  with  serum,  albumen,  or  frogs’  urine,  than  in  those 
sprinkled  with  water ; and  he  has  found  them  most  certainly  in 
preparations  entirely  unmoistened. 

In  one  point  only  he  thinks  Mr  Bowman’s  statements  not  quite 
correct,  viz.  regarding  the  epithelium  of  the  Malpighian  bodies. 
He  observed  within  the  capsule  a complete  epithelium ; but  the 
cilia  he  traced  no  further  than  the  entrance  of  the  capsule.  He 
has  satisfied  himself,  by  preparations  made  with  the  greatest  care, 
that  within  the  capsule  of  the  Malpighian  bodies  there  is  normally 
no  free  cavity.* 

Such  is  an  abstract  of  the  present  state  of  information  on  the 
microscopical  anatomy  of  the  kidney  and  the  Malpighian  bodies. 
It  will  be  seen,  that,  notwithstanding  the  skill  and  dexterity  of  the 
observers,  the  facts  are  contradictory  and  not  easily  reconciled. 
I have  nevertheless  given  them  for  various  reasons ; first,  to  show 
the  great  difficulty  of  the  subject ; secondly,  to  prove  what  is  ad- 
mitted by  Henle,  that  microscopical  anatomy  is  still  in  a transition 
and  imperfect  state ; and  also,  thirdly,  to  enable  readers  to  form 
some  idea  of  the  minute  structure  of  the  glands.  Though  the 
kidney  is  in  some  respects  peculiar  in  its  minute  structure,  yet  it 
agrees  with  other  glandular  organs  in  certain  general  and  leading 
characters ; and  the  exposition  of  these,  however  incomplete,  may 
serve  to  communicate  an  idea  of  the  peculiar  characters  of  glandu- 
lar structure  in  general. 

Before  quitting  the  subject,  however,  it  is  proper  to  observe  that 
one,  if  not  two  of  the  points  on  which  Reichert,  Gerlach,  and  Bid- 
der differ  from  Mr  Bowman,  depend  on  optical  illusions  only ; 
that  he  has  described  correctly  what  he  saw  by  the  microscope ; but 
that,  from  some  cause  not  easily  understood,  he  has  not  given  the 
explanations  of  the  phenomena  which  they  conceive  to  be  correct. 

On  the  uses  of  the  Malpighian  bodies  we  have  no  positive  correct 
information.  All  is  supposition  and  conjecture ; and  those  who 
have  most  studied  these  bodies,  have  been  least  willing  to  speak  with 

• Ueber  Flimmerbewegungen  in  den  Primordial  Nieren  ; von  A.  Kolliker,  Archiv 
for  Anatomie,  Physiologie,  und  Wissenschaftliche  Medicin.  Heft  V.  S.  518.  1845. 


804 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


confidence.  The  fact  that  they  are  placed  among  the  serpentine  re- 
nal ducts,  and  that  they  are  furnished  with  a peculiar  arrangement  of 
capillary  arteries,  may  favour  the  inference  that  they  are  in  some  way 
connected  with  the  secretion  of  urine.  If  the  fact  contended  for  by 
Mr  Bowman,  that  the  Malpighian  bodies  are  connected  with  the 
serpentine  ducts,  were  established,  this  inference  would  be  rendered 
almost  certain.  This  communication,  however,  is  denied  by  Muller 
and  others;  and  Muller  accordingly  maintains  that  the  Malpighian 
bodies  have  no  concern  in  the  secretion  of  urine. 

Mr  Bowman,  on  the  other  hand,  who  thinks  he  has  shown  that  each 
Malpighian  body  is  situate  at  the  remote  or  superior  extremity  of  a 
uriniferous  tube,  and  that  the  tufts  of  vessels  are  a distinct  system 
of  capillaries  inserted  into  the  interior  of  the  tube,  infers  that,  as  the 
arrangement  of  the  vessels  in  the  Malpighian  tufts  is  evidently  de- 
signed to  retard  the  motion  of  blood  through  them,  the  insertion  of 
the  tuft  in  the  extremity  of  the  tube  indicates  that  this  retardation 
is  connected  with  the  secreting  process.  He  concludes,  therefore, 
that  it  is  highly  probable  that  the  use  of  the  Malpighian  tufts  is  to 
afifuse  water  abundantly  and  uniformly  over  the  urine  as  it  is  se- 
creted, so  as  to  ensure  the  perfect  solution  of  all  its  constituents. 
Along  with  this,  he  thinks  that  these  bodies,  by  contributing  tore- 
move  aqueous  matter  from  the  blood,  act  as  a self-adjusting  valve 
or  sluice  to  the  circulation.  The  use  of  the  Malpighian  bodies,  in 
short,  according  to  Mr  Bowman,  is  to  separate  from  the  blood  the 
watery  portion,  according  to  the  necessities  of  the  system. 

I have  only  to  add,  in  order  to  complete  the  description  of  the 
renal  serpentine  ducts,  that  while  they  advance  through  the  cortical 
portion  of  the  kidney  to  its  periphery,  they  are  not  always,  properly 
speaking,  serpentine. 

In  the  horse,  for  instance,  in  which  they  are  so  large  that  they 
may  be  perceived  by  the  eye,  at  least  after  injection,  without  the 
microscope,  they  do  not  run  in  the  serpentine  and  tortuous  course, 
which  they  observe  in  man  and  most  other  animals.  They  are  con- 
tinued from  the  straight  ducts,  very  slightly  bending  or  undulating, 
but  still  almost  straight,  for  at  least  one  inch  or  one  inch  and  a- 
half.  As  they  approach  the  surface  of  the  cortical  portion,  these 
undulating  flexures  increase,  and  at  the  very  surface  they  are  com- 
pletely converted  into  serpentine  or  tortuous  tubes. 

In  the  squirrel  also,  the  serpentine  ducts  are  large,  and  united 
by  little  cellular  tissue.  In  that  animal  they  are  seen  without  in- 


STRUCTURE  OF  INDIVIDUAL  GLANDS — TESTES.  805 


jectioD,  by  the  microscope.  The  Bellinian  ducts  advance  straight 
through  the  medullary  cones,  and  then  passing  into  the  cortical 
matter,  become  bent.  They  appear  a little  larger  than  the  medul- 
lary ducts  upon  entering  the  cortical  portion. 

§ V. THE  TESTIS. 

In  the  Insect  tribes  and  Articulate  animals,  the  iesfes  assume 
an  endless  variety  of  forms.  All,  indeed,  consist  of  tubules  mostly 
simple ; but  these  are  arranged  in  so  great  a variety  of  forms,  that 
it  is  extremely  difficult  to  give  a short,  and  at  the  same  time  accu- 
rate view  of  these  forms. 

In  Fishes,  the  organs  corresponding  to  Testes  appear  to  be  con- 
structed in  two  different  modes.  1.  For  the  most  part,  the  testes 
are  composed  of  multiplied  seminiferous  canals  or  ducts.  2.  Less 
frequently  the  testes  are  entirely  solid,  and  are  composed  of  globules 
without  internal  canals,  and  without  deferent  duct ; the  substance  of 
which  passes  from  the  external  surface  into  the  cavity  of  the  abdo- 
men, from  which  it  is  conveyed  outwards  by  one  single  orifice,  ex- 
actly as  the  ova.  The  best  examples  of  these  structures  are  seen 
in  the  eel  and  •petromyzon.  In  such  animals  the  ova  and  the  testes, 
or  matter  com'posing  the  testes,  are  so  similar,  that  they  are  often 
confounded. 

In  the  herrinar  and  shad  the  structure  is  the  following.  From 
the  eflferent  duct,  running  by  the  side  or  margin  of  the  milt  ( Tes- 
tis), the  largest  tubules  proceed  close  to  each  other,  approaching  to 
the  lobes  attached  to  the  common  duct.  But  the  further  division 
is  efiected,  not  only  by  ramification,  but  also  by  numberless  reticu- 
lar anastomoses,  so  that  almost  the  whole  substance  of  the  testis 
or  milt  consists,  in  the  month  of  May,  of  anastomoses  of  large 
ducts  filled  with  seminal  fluid,  which  are  distinctly  seen  by  the 
naked  eye.  From  the  reticulated  anscB,  however,  proceed  also 
other  branching  canals,  variously  separated,  which  terminate  here 
and  there  in  free  but  closed  ends.  Towards  the  outer  margin  and 
at  the  opposite  side  of  the  lobes,  the  branchy  divisions  are  most 
abundant,  while  the  anastomoses  are  less  frequent;  so  that  the 
margin  itself  is  almost  composed  of  straight  twig-like  tubules,  which, 
little  diminished,  terminate  in  the  extreme  margin  and  at  the  sur- 
face with  closed  ends.  The  internal  branches  are  dispersed  in  va- 
rious directions ; all  the  external  and  marginal  ones  proceed  in  a 
straight  course  to  the  surface,  so  that  on  the  surface  of  one  side  of 


806 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  testis,  the  closed  ends  of  the  tubules  project  like  rounded  cor- 
puscnla.  The  disposition  of  the  tubules  is  mostly  known  from  the 
white  seminal  matter  contained,  which  renders  it  more  distinct  than 
the  other  grey  matter. 

The  most  singular  is  the  conformation  of  the  male  genitals  in 
the  rays  and  sharks.  The  glandular  organs  are  of  two  sorts ; one, 
corresponding  to  what  has  been  hitherto  described  as  testes,  con- 
sisting of  globules,  and  not  of  seminal  ducts ; the  other  generally 
regarded  as  the  epididymis,  composed  of  serpentine  canals,  yet  not 
at  all  joined  with  the  globulose  testes.  On  this  account  Muller 
thinks  that  these  bodies  are  not  epididymides,  but  peculiar  glands. 

In  man  the  essential  part  of  the  testis  consists  of  tubuli  semini- 
feri,  or  very  minute  tubules,  which  are  very  numerous,  and  radiate 
from  all  parts  of  the  circumference  of  the  organ  to  the  centre,  or 
mediastinum  testis,  making  numberless  convolutions,  which  pro- 
gressively diminish  as  they  approach  the  rete  testis.  Two  or  more 
of  the  tubuli  being  collected  together,  and  invested  by  a common 
cellular  tunic,  form  a lobule  of  a conical  shape,  with  its  apex  ter- 
minating in  the  corpus  Highmorianum.  The  lobules  thus  formed 
are  not  entirely  distinct,  but  communicate  with  neighbouring  lo- 
bules, the  process  investing  them  being  incomplete.  Krause  esti- 
mates their  number  between  404  and  484. 

The  tubuli  of  which  they  are  composed  are  of  a white  colour, 
and  uniform  in  size ; but  their  calibre  varies  in  different  subjects, 
and  in  different  periods  of  life,  and  different  states  of  tbe  systetn.^j 
They  are  larger  in  young  adults,  and  when  distended  with  semenj^ 
than  in  aged  persons,  and  when  the  gland  is  in  a state  of  rest.^ 
From  a table  of  measurements'made  by  Mr  Gulliver,  and  publish^ 
ed  in  tbe  proceedings  of  the  Zoological  Society,  their  diameter  ap- 
pears to  have  varied  from  the  1-1 12th  to  the  l-77th  part  of  an 
English  inch,  and  from  the  l-160th  to  the  1-lOOth  part  of  an  inch 
in  adults;  and  in  children  and  infants,  from  the  l-400th  to  the 
l-230th  part  of  an  English  inch.  Observers,  however,  vary  as  to 
the  diameter  of  these  tubuli.  The  average  diameter  of  the  unin- 
jected canal  is  estimated  by  Muller  at  l-18th  of  a line,  = l-180th 
of  an  inch,  and  by  Lauth,  l-185th  of  an  inch.  Krause  found  the 
tubrdi  when  filled  with  semen  to  measure  about  one-twelfth  of  one 
line,  = l-120th  of  an  inch,  and  in  old  men  and  youths  about  l-16di 
of  a line,  or  1-I60tb  part  of  an  inch. 

As  to  their  number  and  their  length  little  seems  ascertained. 


STRUCTURE  OF  INDITIDUAL  GLANDS — TESTES. 


807 


Monro  estimated  the  number  of  seminiferous  tubes  at  300 ; while 
Lauth  made  their  average  number  840.  The  latter  author  esti- 
mated the  mean  length  of  all  the  ducts  united  at  1750  feet.  The 
individual  ducts  he  found  to  vary  in  length,  the  mean  being  25 
inches.  Krause  estimated  their  entire  length  at  1015  feet. 

That  the  membrane  composing  the  tubuli  is  of  a mucous  charac- 
ter has  been  proved  by  microscopic  examination  ; and  it  is  further 
continuous  with  the  mucous  surface  of  the  genito-urinary  system. 
There  is  no  appearance  of  interlobular  substance.  The  ducts  are 
connected  by  a loose  network  of  vessels,  and  consequently  may  be 
easily  separated  and  unravelled.  The  tubes  are  usually  injected 
with  mercury,  and  in  this  state  are  shown  in  most  anatomical  col- 
lections. Sir  Astley  Cooper  injected  the  tubes  with  size  ; but  of 
the  method  which  he  followed  no  account  is  given. 

When  the  tubuli  are  unravelled,  they  are  found  to  divide  and  to 
form  numerous  anastomotic  unions,  which  increase  in  frequency  as 
they  approach  the  circumference  of  the  gland.  The  tubuli  thus 
form  one  large  communicating  network,  in  which  it  is  impossible 
to  isolate  completely  either  one  duct  or  one  lobule.  In  one  in- 
stance only  did  Lauth,  who  discovered  these  anastomoses  of  the  se- 
miniferous tubuli,  find  a duct  terminating  in  a blind  sac ; and  this 
he  regards  as  an  exception.  Blind  sacs  have  been  more  frequently 
found,  however,  by  Krause. 

The  convolutions  of  the  seminiferous  tubes  diminish  in  number 
as  they  approach  the  mediastinum  and  cease  at  a distance  of  from 
one  to  two  lines,  where  two  or  more  unite  to  form  one  single, 
straight  duct  termed  vas  rectum,  whith  joins  the  rete  testis  at  a 
right  angle.  The  vasa  recta  are  very  slender,  and  easily  give  way 
when  injected.  Their  calibre,  which  is  greater  than  that  of  the  se- 
minal tubes,  is  estimated  by  Lauth  at  l-108th  of  an  inch.  Their 
number  Haller  reckoned  at  20 ; but  it  is  believed  that  they  are 
more  numerous. 

The  rete  testis  is  formed  of  a plexus  of  seminal  tubes,  which  oc- 
cupies the  Corpus  Highmorianum  or  mediastinum  testis.  The  vasa 
recta,  after  penetrating  the  walls  of  the  corpus,  terminate  in  from 
seven  to  thirteen  vessels,  which,  running  parallel  to  each  other  in  a , 
waving  course,  and  frequently  dividing  and  anastomosing,  form  the 
rete  testis.  The  mean  diameter  of  these  vessels  Lauth  found  in  in- 
jected preparations  to  be  l-72d  of  an  inch. 

From  the  upper  part  of  the  rete  thus  formed  issue  vessels  in  nuin- 


808 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


ber  about  twelve  or  fourteen,  but  sometimes  rising  to  thirty,  which 
are  named  vasa  efferentia.  These  ducts,  which  are  arranged  in  co- 
nical shape,  and  hence  named  coni  vasculosi,  run  straight  for  the 
space  of  one  or  two  lines,  forming  convolutions  which  become  nu- 
merous and  close  as  the  vessels  recede  from  the  testis.  Lauth,  es- 
timating the  average  length  at  7 inches  4 lines,  and  their  number 
at  thirteen,  makes  the  united  length  to  be  nearly  8 feet.  After  form- 
ing the  vascular  tubes,  already  mentioned,  they  successively  join 
one  single  duct,  the  canal  of  the  epididymis,  at  irregular  intervals, 
the  intermediate  spaces  of  the  duct  varying  in  length  from  half-an- 
inch  to  6 inches.  These  efferent  ducts  are  more  slender  than  the 
canal  of  the  epididymis,  and  frequently  give  way  under  the  pres- 
sure of  the  column  of  mercury. 

While  the  vascular  cones  form  a round  bulky  mass,  which  has 
been  named  the  head,  or  (jlobus  major ^ of  the  epididymis,  the  con- 
volutions made  by  the  efferent  ducts  form  the  body  and  tail,  to 
which  also  the  name  oi  globus  minor  has  been  applied. 

A shut  canal  or  duct,  usually  attached  to  the  tail  of  the  epidi- 
dymis, and  with  a blind  appendage  or  termination,  constitutes  what 
has  been  named  the  vasculum  aberrans.  The  length  of  this  duct 
varies  from  1 to  12  or  14  inches,  and  it  is  always  more  or  less  con- 
voluted. It  is  not  constant ; nor  is  its  use  perfectly  known.  Mr 
Curling  infers  that  it  serves  no  particular  purpose,  and  that  it  is  a 
mere  diverticulum,  or  process  similar  to  those  observed  in  the  in- 
testinal canal. 

The  canal  of  the  epididymis  as  it  approaches  the  level  of  that 
body  becomes  larger,  and  forms  then  the  vas  deferens  or  excretory 
duct  of  the  testicle.  The  course,  direction,  and  termination  of  this 
tube  are  well  known. 

The  spermatic  artery  or  arteries,  or  those  which  supply  the  testis, 
arise  either  from  the  aorta  immediately  below  the  renal  artery,  or 
come  off  in  one  trunk,  common  to  it  and  the  renal  artery,  a mode 
of  origin  connected  with  the  site  of  the  organ  in  the  foetus,  when  it 
is  placed  near  the  kidney  on  each  side  of  the  spinal  column.  From 
the  point  now  specified  they  descend  behind  the  peritoneum,  form- 
ing many  convolutions  and  tortuous  windings,  obliquely  across  the 
psoas  muscle  and  ureter,  to  which  each  artery  gives  branches,  and, 
entering  the  inguinal  canal  by  the  internal  ring,  they  are  joined 
with  the  chord  and  reach  the  gland.  Their  subsequent  distribu- 
tion is  described  by  Sir  Astley  Cooper  in  the  following  manner. 


STRUCTUEE  OF  INDIVIDUAL  GLANDS TESTES. 


809 


“ When  the  artery  reaches  from  one  to  three  inches  from  the 
epididymis  it  divides  into  two  branches,  which  descend  to  the  tes- 
ticle, and  its  inner  side,  opposite  to  that  on  which  the  epididymis  is 
placed ; one  passing  on  the  anterior  and  upper,  the  other  to  the 
posterior  and  lower  part  of  the  testis.  From  the  anterior  branch 
the  vessels  of  the  epididymis  arise.  First,  one  passes  to  its  head  ; 
secondly,  another  to  its  body  ; and  thirdly,  one  to  the  tail  and  the 
first  convolutions  of  the  vas  deferens^  communicating  freely  with 
the  deferential  artery.  The  spermatic  artery,  after  giving  off 
branches  to  the  epididymis,  enters  the  testis  by  penetrating  the  outer 
layer  of  the  tunica  rdbuginea  ; and,  dividing  upon  its  vascular  layer, 
they  form  an  arch  by  tbeir  junction  at  the  lower  part  of  the  testis, 
from  which  numerous  vessels  pass  upwards ; and  then  descending, 
they  supply  the  lobes  of  the  tuhidi  seminiferi.  Besides  this  lower 
arch  there  is  another  passing  in  the  direction  of  the  rete,  extremely 
convoluted  in  its  course,  and  forming  an  anastomosis  between  the 
principal  branches.  The  testis  receives  a further  supply  of  blood 
from  another  vessel,  the  artery  of  the  vas  deferens,  or  posterior 
spermatic  artery,  which  arises  from  one  of  the  vesical  arteries, 
branches  of  their  internal  iliac.  This  artery  divides  into  two  sets 
of  branches,  one  set  descending  to  the  vesicula  seminalis  and  to  the 
termination  of  the  vas  deferens ; the  other  ascending  upon  the  vas 
deferens,  runs  in  a serpentine  direction  upon  the  coat  of  that  vessel, 
passing  through  the  whole  length  of  the  spermatic  chord;  and 
when  it  reaches  the  tail  of  the  epididymis,  it  divides  into  two  sets  of 
branches,  one  advancing  to  unite  with  the  spermatic  artery  to  supply 
the  testis  and  epididymis,  the  other  passing  backwards  to  the  tunica 
vaginalis  and  cremaster.” 

The  spermatic  veins  issue  from  the  testis  in  three  sets ; one  from 
the  rete  and  tubuli ; another  from  the  vascular  layer  of  the  tunica 
albuginea  ; and  a third  from  the  lower  extremity  of  the  vas  deferens. 
The  veins  of  the  testis  pass  in  three  courses  into  the  beginning  of 
the  spermatic  chord.  Of  these,  two  quit  the  back  of  the  testis,  one 
at  its  anterior  and  upper  part;  and  a second  at  its  centre,  and 
thereafter  from  two  to  three  inches  are  united  into  one.  The  other 
column  accompanies  the  vas  deferens.  The  veins  of  the  epididymis, 
issuing  from  the  head,  body,  and  tail,  with  some  from  the  vas  defe- 
rens, terminate  in  the  veins  of  the  spermatic  chord.  The  veins,  af- 
ter quitting  the  testis,  become  very  tortuous,  and  forming  frequent 
divisions  and  inosculations,  constitute  the  plexus  named  vasa  pam- 


810 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


piniformia.  After  entering  the  pelvis  they  form  one  or  two  veins 
which  terminate  on  the  right  side  of  the  vena  cava  inferior,  and  on 
the  left  in  the  renal  vein,  though  this  is  liable  to  some  variety. 
The  left  spermatic  vein  passes  under  the  sigmoid  flexure  of  the  co- 
lon,— a circumstance  important  to  be  remembered,  in  certain  mor- 
bid states  of  the  gland  and  its  vessels. 

Several  anatomists  represent  the  spermatic  veins  to  be  void  of 
valves  ; and  to  this  circumstance  ascribe  the  occurrence  of  va- 
ricocele. Mr  Curling  states,  that  he  has  several  times  injected 
these  veins  with  alcohol,  and  on  laying  them  open,  he  observed 
valves  in  the  larger  veins,  and  found  the  passage  of  the  alcohol  ar- 
rested by  the  valves.  Valves  are  not  seen  near  the  testis,  or  in  the 
small  veins  forming  the  plexus,  nor  did  Mr  Curling  observe  them 
within  the  abdomen. 

§ VI. THE  MAMMA. 

The  Mammalia  are  the  only  class  of  vertebrated  animals  which 
possess  the  glands  called  Mammae  or  Breasts ; Birds,  Reptiles, 
and  Fishes,  being  destitute  of  these  ; and  in  this  order  the  confor- 
mation of  these  glands  appears  under  two  forms. 

1.  In  the  higher  Mammalia  and  in  man  the  elementary  particles 
of  the  Mamm^,  or  the  ends  of  the  lactiferous  tubes,  are  small  vesi- 
culse,  joined  to  stalks  by  small  branches  of  lactiferous  tubules 
in  the  manner  of  cluster  of  grapes  or  berries,  and  enclosed 
by  a very  delicate  cellular  tissue.  These  acini  of  vesicles  constitute 
the  smallest  lobules.  Several  clustering  acini  united  to  the  twigs 
of  a larger  branch  form  a large  tubule  or  one  of  the  second  order ; 
and  when  several  of  these  are  conjoined  they  form  a tubule  of  the 
third  order.  These  lactiferous  tubes  then  uniting  form  trunks  of 
lactiferous  ducts,  which,  either  united  open  into  the  nipple,  as  in 
the  udder  of  the  Ruminants,  or  separately  perforate  the  nipple, 
as  in  the  human  female  and  various  other  mammalia. 

2.  The  second  form  of  mamma  is  more  rarely  met  with,  and  is 
observed  in  families  of  the  mammalia,  which  may  be  regarded  as 
the  lowest  in  that  class  ; namely,  in  the  Cetacea,  and  in  the  duck- 
bill {ornithorhyncus  paradoxus),  and  probably  in  the  echidna.  In  these 
animals  the  structure  is  reduced  to  that  of  a glandular  organ,  sucli 
as  first  presents  itself  in  the  lowest  mammalia,  or  in  the  most  simple 
form,  that  is  in  the  shape  of  closed  intestinula,  collected  in  one  mass. 


GLANDULAR  ORGANS. 


811 


CHAPTER  II. 

MORBID  STATES  OF  THE  GLANDULAR  ORGANS. 

The  morbid  states  of  the  glandular  organs  are  very  numerous 
and  varied ; and  if  we  remember  how  often  their  function  is  dis- 
ordered, to  how  many  morbid  changes  their  secreted  products  are 
liable,  how  many  changes  may  take  place  in  their  circulation,  in- 
dependent of  changes  in  their  structure,  we  must  allow  that 
there  is  scarcely  a texture  in  the  whole  frame  which  presents  so 
many  forms  of  diseased  action  as  the  glands. 

It  would  lead  me  into  a field  too  extensive  to  consider  all  the 
varieties  of  disorder  and  diseased  action  to  which  I have  now  ad- 
verted. It  must  also  be  admitted,  that  the  subject  is  in  many  re- 
spects imperfectly  known ; and  that  the  consideration  of  various 
changes  incident  to  glandular  action  would  lead  me  into  inquiries 
inconsistent  with  the  nature  of  the  present  work.  I propose,  there- 
fore, to  confine  the  present  sketch  very  much,  if  not  entirely,  to  the 
morbid  states  most  frequently  taking  place  in  the  system  of  the  se- 
creting glands. 

Section  I. 

general  observations  on  disorders  of  the  secreting 

GLANDS. 

The  glands,  from  being  liberally  supplied  with  blood-vessels,  are 
liable  to  he  affected  by  all  the  changes  which  take  place  in  the  vas- 
cular system.  The  blood,  indeed,  may  be  regarded  as  the  first 
great  agent  which  affects  the  state  of  the  functions  of  the  secreting 
glands.  All  substances  taken  into  the  blood  are  circulated  to  the 
glands,  and  in  a degree  greater  or  less  affect  their  secretions. 
Thus,  mercury  and  its  preparations,  which  have  been  erroneously 
supposed  to  act  on  the  salivary  glands  only,  act  at  the  same  time 
on  the  pancreas,  the  liver,  and  the  kidneys.  In  the  same  manner 
also,  spirituous  liquors  or  articles  containing  them  are  absorbed  by 
the  veins,  circulated  and  conveyed  to  the  different  glands,  and  in 


812 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


this  manner  always  cause  unnatural  excitement  and  irritation  in 
their  vessels  and  elementary  particles.  Saline  substances  also 
reach  the  glands  and  act  on  them  sometimes  favourably,  sometimes 
detrimentally. 

Glands  are  liable  to  inflammation,  acute  and  chronic,  and  all 
their  usual  effects  and  consequences ; to  hemorrhage ; to  indura- 
tion ; to  hypertrophy ; to  atrophy ; to  interstitial  deposits  of  new 
matter  ; to  the  obstruction  of  their  ducts  by  blood,  lymph,  and  the 
products  of  secretion  ; to  various  changes  in  structure  in  the  ele- 
mentary or  ultimate  particles ; and  to  several  of  the  heterologous 
depths. 

When  glandular  organs  are  affected  by  inflammation,  that  pro- 
cess may  affect  either  the  component  tubes  or  the  delicate  filamen- 
tous tissue  by  which  these  tubes  are  united ; or  both  at  the  same 
time.  When  the  process  affects  the  tubes,  if  it  do  not  terminate  in 
resolution,  that  is,  if  the  orgasm,  after  subsisting  for  some  time,  does 
not  subside  without  giving  rise  to  inflammatory  products,  it  causes 
effusion  of  plasma,  or  of  blood  within  the  tubes,  which  are  then  for 
the  time  obliterated.  In  this  case  the  gland  is  enlarged  and  indu- 
rated, sometimes  irregular,  is  the  seat  of  dull  pain  and  weight,  and 
secretion  is  almost  impracticable. 

In  certain  favourable  cases,  in  which  the  plasma  or  blood  is  ef- 
fused in  small  quantity,  it  does  not  undergo  coagulation ; and  the 
tubes  may  remain  more  or  less  pervious  ; or  even,  after  a time,  may 
recover  entirely  their  permeability.  Instances  of  this  undoubtedly 
take  place  both  in  inflammation  of  the  liver  and  in  that  of  the  kid- 
neys. 

In  other  instances,  however,  in  which  the  effusion  is  abundant, 
the  gland  remains  hard  and  enlarged  for  a long  time,  sometimes 
for  life. 

When  inflammation  affects  the  outside  of  the  tubes  and  acini,  or 
elementary  particles,  and  the  connecting  tissue,  it  more  commonly 
causes  the  effusion  of  purulent  matter,  in  one  or  more  distinct  cysts 
or  abscesses. 

Lastly,  inflammation  often  attacks  first  and  principally  the  ex- 
cretory duct  and  its  divisions,  and  terminates  in  effusion  of  matter  ^ J 
more  or  less  copious.  This  either  escapes  by  the  general  duct;  or, 
if  i do  not  readily  escape,  or  is  entirely  confined,  the  duct  and  all  the 
communicating  parts  become  greatly  distended,  containing  conside-;',^ 
rable  quantities  of  purulent  matter,  and  their  lining  membrane  co- 
vered with  a coating  of  lymph ; and  in  this  case  the  gland  appears  ^ - 


GLANDULAR  ORGANS — LACRYMAL  GLAND. 


813 


to  contain  a number  of  separate  abscesses.  If,  however,  these  be 
carefully  examined,  it  is  seen  that  neither  the  gland  nor  the  tex- 
ture of  the  ducts  is  destroyed ; that  the  former  is  enlarged  and  ex- 
tenuated by  the  distension  of  the  ducts ; while  the  apparent  ab- 
scesses are  formed  by  the  latter.  This  takes  place  in  the  kidneys 
and  prostate  gland. 

Inflammation  of  strumous  character  is  liable  to  affect  the  secret- 
ing glands,  more  especially  the  female  breast,  the  testes  and  pros- 
tate gland  of  the  male,  and  the  kidneys  and  parotids  in  both  sexes. 
The  effects  of  this  process,  which  is  chronic  in  duration,  and  insidi- 
ous and  not  well-marked  in  symptoms,  are  denoted  by  the  deposit, 
in  general,  within  the  tubules  of  the  glands  of  semifluid  or  fluid  ty- 
romatous  matter,  that  is  to  say,  an  albuminous  animal  product, 
which,  though  it  undergoes  coagulation,  is  nevertheless  remarkable 
for  showing  little  or  no  tendency  to  become  organized.  This  sub- 
stance, found  in  tbe  shape  of  putty-like  matter,  caseous  matter,  or 
caseous  mixed  with  calcareous  matter,  presents  few  or  no  blood- 
vessels, bas  no  independent  circulation,  and,  in  short,  gives  evidence 
of  possessing  a very  low  degree  of  vitality,  or  rather  nothing  of  that 
property  at  all.  As  already  stated,  it  is  found  in  the  ducts  of  the 
testes  and  prostate  gland,  in  which  its  presence  gives  rise  to  consi- 
derable irregular  swelling  and  pain  by  pressure  on  adjoining  parts ; 
it  is  also  seen  in  the  mamma,  where  it  likewise  causes  considerable 
irregular  swelling ; and  it  may  affect  either  the  serpentine  ducts  of 
the  kidney,  or  the  calyces  of  that  gland. 

Section  II. 

§ I.  THE  LACRYMAL  AND  SALIVARY  GLANDS. 

These  glands  are  liable  to  inflammation,  acute  and  chronic ; 
the  latter  most  usual. 

Inflammation  of  the  lacrymal  gland  is  certainly  rare,  unless  as 
the  effect  of  injury  or  the  extension  of  inflammation  of  the  conjunc- 
tiva into  its  ducts.  Most  usually  it  is  chronic.  An  instance  is 
mentioned  by  Beer  ;*  and  the  disease  is  described  by  Reil  and  Be- 
nedict. Hemorrhage  takes  place  from  it  sometimes  as  vicarious  of 
menstruation,  sometimes  without  any  obvious  connection  with  this 
cause.  Hemorrhage  appearing  at  the  eyes  in  purpura  is  most 
probably  from  the  conjunctiva. 

* Georg.  Jos.  Beer  Auswahl  aus  dem  Tagebuch  eines  practrischen  Augenarztes,  n.  2. 
Wien,  1800. 


814 


GENEIIAL  AND  PATHOLOGICAL  ANATOMY. 


The  lacryinal  gland  may  be  enlarged  from  strumous  disorder  to 
the  size  of  a nut.  It  then  makes  a distinct  tumour  at  the  exterior 
and  superior  angle  of  the  eye  beneath  the  orbital  plates. 

Schmidt  admitted  that  inflammation  of  the  lacrymal  gland  alone 
can  scarcely  be  said  to  take  place  ; because,  the  disease  thus  desig- 
nated is  rather  inflammation  of  the  entire  orbit,  that  is  of  the  or- 
bital cellular  tissue,  embracing  also  the  gland.*  This  view  is 
adopted  by  Benedict,  who  devotes  a whole  chapter  to  the  descrip- 
tion of  the  disease  and  its  eflects.  As  described  by  this  author,  it 
is  manifestly  an  acute  inflammation  of  the  ophthalmic  cellular  tis- 
sue, with  some  symptoms  indicative  of  extension  to  the  cerebral 
membranes.  Thus,  not  only  is  there  pain  in  the  eyeball  and  orbit, 
but  pain  of  the  head,  delirium,  want  of  sleep,  and  great  suflfering. 
The  characteristic  symptoms  are  the  sense  of  something  in  the  or- 
bit above  the  eye,  the  feeling  of  the  orbit  being  too  small  for  the 
eye,  as  if  the  eyeball  were  thrust  out  of  it ; then  swelling  of  the  up- 
per eyelid,  proceeding  generally  to  a great  degree ; and  at  last  the 
formation  of  matter,  which  points  in  this  situation,  or  immediately 
beneath  it.f  A similar  account  is  given  by  Weller. 

It  is  manifest  that  this  is  the  account  of  general  inflammation 
of  the  orbital  celluloso-adipose  tissue ; and  not  of  the  lacrymal 
gland  alone.  The  gland,  however,  may  be  affected ; but  that  is 
only  in  a slight  degree. 

This  disorder  may  terminate  in  one  of  three  modes.  First,  un- 
der symptoms  of  complete  phrenitis,  the  patient  dies  ; secondly,  it 
may  terminate  in  abscess  of  the  orbital  tissue ; or,  thirdly,  complete 
ophthalmitis  is  associated  with  inflammation  of  the  eyeball,  and  sup- 
puration of  the  latter  is  superadded  to  abscess  of  the  orbit. 

Next  to  resolution  abscess  of  the  orbital  tissue  is  the  most  favour- 
able result.  Benedict  states  that  when  this  does  not  take  place, 
or  an  opening  is  neglected,  death  has  been  the  result,  by  the  tran- 
sit of  the  disease  to  the  brain ; and  on  inspecting  the  parts,  the  an- 
terior lobe  has  been  found  inflamed,  and  a collection  of  purulent 
matter,  both  on  the  surface  of  the  cranium,  frontal  bone,  and  in 
the  orbit. 

When  the  lacrymal  gland  is  affected  by  chronic  inflammation, 
the  eye  is  protruded,  the  optic  nerve  suffers  from  pressure,  and 

* Johann.  Adam  Schmidt,  iiber  die  Krankheiten  des  Thranenorgans,  mit  4 Kup- 
fertaf,  gr.  8vo.  Wien,  1803. 

f Traugott  Guilelmi  Gustavi  Benedict,  de  Morbis  Oculi  Humani  Inflammatoriis. 
Lib.  xxiii.  Lipsije,  1811.  Liber  7imus,  § 153,  p.  82. 


GLANDULAR  ORGANS — LACRYMAL  GLAND. 


815 


amaurosis  follows  ;*  or  the  vitreous  humor  and  lens  are  so  much 
compressed,  that  sight  is  greatly  impaired. 

Even  without  this  compression  the  sight  may  be  lost. 

This  is  probably  owing  to  the  nervous  connection  between  the 
divisions  of  the  first  part  of  the  fifth  nerve, — one  of  which  supplies 
the  lacrymal  gland, — and  the  branches  of  the  same  nerve,  which  are 
distributed  to  the  ciliary  processes. 

Portal  states,  that  he  found  it  affected  with  scirrhus,  and  even 
proceeding  to  ulceration  in  dead  bodies ; especially  in  the  body  of 
one  female  who  had  cancer  in  both  mammae,  and  who  some  time 
before  death  had  an  attack  of  chronic  ophthalmia. 

It  is  often  difficult  to  distinguish  between  mere  induration,  the 
effect  of  chronic  inflammation  and  scirrhus  of  the  gland.  In  both  ^ 
the  gland  is  hard  and  enlarged,  and  causes  a prominent  swelling, 
more  or  less  distinct,  at  the  superior  outer  angle  of  the  orbit.  The 
eye  is  pressed  downwards  ; and  more  or  less  ophthalmia  affects  the 
palpebral  and  ocular  conjunctiva.  At  first  the  secretion  of  tears 
is  augmented  ; but  after  the  disease  has  continued  some  time  it  is 
diminished ; and  the  peculiar  symptom  called  xerophthalmia  or 
preternatural  dryness  of  the  eye  is  induced. 

The  disease  named  cancer  of  the  e}'^eball  often  originates  either 
in  the  lacrymal  gland,  or  in  the  caruncula  lacrymalis.  Conversely, 
if  scirrhus  affect  the  eyeball,  it  may  spread  to  the  lacrymal  gland. 

Guerin  states  that  he  extirpated  a lacrymal  gland  affected  with  scir- 
rhus, while  the  eye  appears  to  have  been  unaffected.  This  he  did  with 
so  great  dexterity,  that  the  rectus  externus  muscle  was  not  touched. 
The  gland  formed  a swelling  so  considerable,  that  it  covered  com- 
pletely the  globe  of  the  eye.  The  eye,  however,  was  found  quite 
sound  behind  the  tumour  of  the  lacrymal  gland.  Richerand,  who 
knew  no  other  instance  of  extirpation  of  the  gland  alone,  is  inclined 
to  believe  the  case  solitary.  It  is  certainly  much  more  common  to 
remove  the  gland,  sound  or  diseased,  in  removing  the  eye,  than  to 
remove  the  diseased  gland  alone  without  the  eye. 

The  lacrymal  gland  has,  nevertheless,  been  repeatedly  removed 
since  that  time.  Thus  it  was  removed  by  Duval  de  Rennes,t  by 
Mr  Travers,!  by  Mr  O’Beirne  in  1820,§  by  Mr  Todd  in  1821,H 

* Reil,  Memorabilia  Clinica.  Vol.  i.  Fascicul.  i p.  118. 

t J.  L.  Duval  sur  quelques  Affections  Douloureuses  de  la  Face.  Paris,  1814.  8vo. 

t Synopsis  of  Diseases  of  the  Eye  and  their  Treatment.  London,  1820  and  1824, 
p.  233. 

§ On  Diseases  of  the  Lacrymal  Gland,  by  Charles  H.  Todd.  Dublin  Hospital  Re- 
ports, Vol.  iii.  p.  407. 

II  Ibid. 


816 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


by  Daviel  in  1829,  by  Lawrence  in  1826  and  1828,*  and  by  M. 
Jules  Cloquet  in  1835.f 

It  is  not  perfectly  certain,  whether  in  all  these  cases  the  gland 
was  affected  by  genuine  scirrhus.  It  is  certain  that  in  its  site  was 
a hard  firm  body,  generally  much  swelled,  and  forcing  the  eyeball 
downwards.  In  each  of  the  cases  almost  the  structure  of  the  gland 
was  different.  In  two  cases,  in  which  Mr  Lawrence  operated,  he 
allows  that  the  gland  in  respect  of  hardness  might  have  been  called 
scirrhus ; but  he  adds,  that  he  saw  no  reason  for  suspecting  the 
disease  to  be  malignant.  If  this  latter  conclusion  be  admitted, 
then  it  follow^s  that  these  are  examples  of  simple  induration  (sklc- 
roma)  of  glands.  In  all  these  cases,  however,  the  gland  is  more 
or  less  enlarged,  sometimes  very  much  so. 

In  those  cases  in  which  the  lacrymal  gland  has  been  examined 
after  extirpation,  it  has  been  observed  that  the  elementary  particles 
or  granules  were  hard  and  enlarged,  chiefly  by  the  effusion  of 
lymph.  But  the  appearances  vary  in  different  instances. 

Schmidt,  and  afterwards  Beer,  describe  the  formation  of  true 
hydatids  as  occurring  in  the  lacrymal  gland.  Their  pressure 
causes  a tumour  at  the  upper  part  of  the  orbit,  and  some  degree 
of  exophthalmia. 

Among  the  salivary  glands,  the  morbid  states  of  the  parotid  have 
attracted  most  attention. 

It  is  known  that  the  parotid  and  soda  parotidis  are  liable  to 
acute  inflammation,  forming  the  disease  known  by  the  popular  name 
of  Mumps  and  Branks,  and  also  to  various  chronic  disorders.  Of 
the  former  I need  scarcely  speak  in  this  place ; because,  though  a 
disease  not  unimportant,  yet  it  is  rarely  the  object  of  attention  to 
the  pathological  inquirer ; and  the  accounts  given  in  the  ordinary 
treatises  contain  all  the  information  which  it  is  necessary  to  possess 
on  the  affection!  and  the  diseases  in  conjunction  with  which  it  ap- 
pears either  as  an  effect  or  a part. 

One  or  two  points  only  require  to  be  here  noticed.  The  swelling 
which  takes  place  in  the  parotid  region  in  remittent  fever,  typhous 

* A Treatise  on  the  Diseases  of  the  Eye,  by  William  Lawrence,  P.  R.  S.  London, 
1833.  Chapter  xxix.  sect.  i. 

-f-  Du  Squirrhe  de  la  Glande  Lacrymale  et  de  I’Ablation  de  cette  Glande,  par  G. 
E.  Maslieurat-I.agemard.  Archives  Generales,  iiie.  et  Nouvelle  Serie.  T.  vii.  ou  T. 
lii.  Paris,  1840.  P.  90. 

J Elements  of  Practice  of  Medicine.  Vol.  ii.  Book  ii.  Chapter  v.  § iv.  p.  410. 


PAROTID  GLAI^D. — DISEASES. 


817 


fever,  synochus^  scarlet  fever,  and  similar  diseases,  appeal's  to  be 
seated  rather  in  the  surrounding  cellular  and  adipose  tissue  than 
in  the  parotid  gland.  It  occasionally  proceeds  to  suppuration  ; and 
this  I have  seen  it  do,  notwithstanding  the  use  of  means  calculated 
to  obviate  this  termination.  This  result  is  supposed  not  to  be  un- 
favourable ; and  many  physicians  prefer  promoting  it  by  the  use  of 
stimulating  applications.  At  the  same  time,  it  must  be  observed 
that  suppuration  in  this  region  is  not  always  a favourable  result. 
The  following  case  given  by  Monteggia  is  in  point. 

In  a man  of  60  years  a swelling  took  place,  in  the  course  of 
fever,  in  the  right  parotid  region.  This  speedily  subsided,  and 
was  followed  by  a similar  swelling  in  the  left  parotid  region,  which 
terminated  in  abscess.  This  being  evacuated  by  an  incision  made 
below  the  ear,  the  opening  continued  for  one  month  discharging 
much  matter,  and  a little  coming  away  daily  by  the  ear-hole.  The 
patient,  in  the  meantime,  though  the  original  disease  was  gone,  did 
not  recover  properly,  continued  long  languishing,  and  at  length, 
becoming  worse,  died  comatose. 

Inspection  of  the  body  disclosed  the  following  facts.  The  whole 
cellular  tissue  on  the  left  side  of  the  head  was  loaded  with  fluid. 
The  parotid  gland,  contracted,  rigid,  and  hardish,  was  marked  in 
various  places  with  red  points.  Trom  the  external  site  of  the  in- 
cision an  ulcerated  passage  or  sinus  led  to  the  meatus  auditorius, 
the  eroded  cartilage  of  which  was  partly  seen.  The  adjoining  part 
of  the  bony  canal,  with  the  root  of  the  zygomatic  process,  were 
struck  with  caries.  In  the  meatus  itself  were  some  loose  osseous 
fragments,  along  with  some  testaceous  remains  of  some  insect  dead 
in  this  situation.  The  temporal  muscle  presented  unequivocal  traces 
of  previous  inflammation  ; and  beneath  it  were  some  drops  of  pu- 
rulent matter  on  the  surface  of  skull.  The  intermeningeal  space, 
when  the  skull  was  opened,  effused  a large  quantity  of  fluid  on  the 
left  side,  the  veins  here  being,  besides,  unusually  turgid.  When 
the  dura  mater  was  detached  from  the  inner  surface  of  the  skull  on 
this  side,  there  appeared  a purulent  space  half  an  inch  broad  on  the 
surface  of  the  petrous  process,  where  foramina  of  Valsalva  lead 
to  cavity  of  the  tympanum. 

The  purulent  matter,  nevertheless,  did  not  proceed  from  that 
cavity,  in  which  there  was  no  disease.  But  the  suppuration  which 
had  taken  place  between  the  temporal  muscle  and  the  skull,  had 
transmitted  many  drops  into  the  cavity  of  the  skull  by  a small 

3 F 


818 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


aperture  conspicuous  in  the  temporal  bone,  from  which  then  the 
fluid  proceeding  backwards  by  a linear  path  had  dropped  into  the 
space  mentioned  in  the  petrous  portion  of  the  temporal  bone.* 

This  case,  however,  merely  shows,  that  when  extensive  suppura- 
tions take  place  in  certain  situations  and  in  particular  constitutions, 
the  matter  may  find  its  way  into  or  among  important  and  essential 
organs. 

In  almost  all  these  cases  of  suppuration  in  the  parotid  region, 
the  gland  does  not  itself  suppurate,  but  remains  as  described  by 
Monteggia,  shrunk,  dry,  hard,  and  apparently  atrophied. 

§ 2.  The  parotid  gland  and  its  companion  are  liable  to  strumous 
transformation  and  infiltration,  to  chronic  induration,  to  hypertro- 
phy, to  scirrho-carcinoma,  and  to  melanosis. 

In  ordinary  circumstances  enlargement  of  the  parotid  is  most 
commonly  strumous  or  dependent  on  chronic  inflammation.  In 
either  case,  a tumour  variable  in  size  is  formed  at  the  auriculo- 
temporal region,  a little  above  the  angle  of  the  jaw.  When  this 
swelling  is  of  strumous  origin,  it  usually  causes  secondary  inflam- 
mation and  suppuration  of  the  surrounding  cellular  tissue  and  the 
incumbent  skin ; one  opening  or  two  may  take  place ; and  for  a 
considerable  time  a thin  serous  or  sero-purulent  discharge  conti- 
nues. Usually  the  gland  is  not  itself  much  or  seriously  affected  be- 
yond the  swelling  caused  by  infiltration  of  its  ducts  and  acini.  In 
certain  cases,  however,  the  gland  or  its  ducts  seem  to  pass  into  the 
ulcerative  stage  ; and  a long  continued  sore  with  a salivary  fistula 
is  the  result.  In  other  cases  the  ulcerative  communication  appears 
to  be  established  between  Steno’s  duct  only  and  the  surface.  Ul- 
cers and  fistulse  of  this  kind  were  seen  by  Hildanus  and  Chesel- 
den  states,  that  he  saw  patients  with  the  gland  ulcerated,  and  caus- 
ing a constant  effusion  of  saliva,  till,  he  adds,  the  greatest  part  of 
the  gland  was  consumed  by  the  use  of  red  precipitate.  | It  is  not 
easy  to  imagine  the  gland,  that  is  the  substance  of  the  gland,  to  be 
much  consumed  in  this  manner  or  by  this  agent,  without  more 
serious  effects.  But  we  may  admit  that  the  remedy,  by  inducing 
a new  and  more  decided  action,  and  enabling  the  most  healthy 

* Joannis  Baptistae  Monteggia  Fasciculi  Pathologici.  Turici  Helvetiorum,  1793. 
8 VO,  p.  17. 

-f-  One  in  a young  man  of  12.  Observat.  Chirurgic.  Centuria  V.  Obs.  Ixxx.  Op. 
Omnia  Francofurti  ad  Moeniun,  1646.  Folio.  P.  471. 

i The  Anatomy  of  the  Human  Body.  Book  iii.  Chapter  iii.  p.  142.  London, 
1784,  the  12th  edition. 


PAKOTID  GLAND — STRUMOUS  ENLARGEMENT. 


819 


part  of  the  gland  to  assume  proper  action,  had  effected  cicatriza- 
tion. 

Tenon  speaks  of  a tumour  of  the  parotid  gland  which  attains 
a large  size,  yet  he  says  without  change  in  structure.  The  instance 
which  he  describes  took  place  in  a child,  on  the  left  cheek  of  whom 
appeared  a tumour  almost  as  large  as  the  fist,  extending  from  the 
ear  to  the  angle  of  the  lip.  This  tumour,  which  had  grown  gra- 
dually from  the  birth  of  the  child,  was  soft,  white,  indolent,  move- 
able, and  composed  apparently  of  glandular  grains.  It  appeared 
also  traversed  by  large  vessels,  which  formed  in  various  parts  of 
the  skin  networks  of  spiral  form  or  reddish  whorls.  The  child 
died  not  from  the  tumour,  but  from  a different  cause.  Tenon  found 
that  the  tumour  was  formed  by  the  parotid  gland,  which  had  ac- 
quired great  size,  and  exceeded  its  usual  limits.  Large  arteries 
proceeding  from  the  external  carotid  and  external  maxillary  enter- 
ed the  lower  part  of  the  gland.* 

This  seems  to  have  been  an  example  of  simple  strumous  enlarge- 
ment, or  at  most  of  hypertrophy  occurring  in  the  strumous.  If 
there  was  no  perceptible  change  in  structure,  that  must  be  ascribed 
to  the  short  duration  of  the  affection  ; for  the  enlarged  state  of  the 
arteries  shows  that  they  were  conveying  much  blood  into  the  gland  ; 
and  though  this  seemed  only  to  be  giving  rise  to  simple  enlarge- 
ment, it  is  impossible  to  doubt,  that  the  characteristic  deposition  of 
strumous  disorganization  would  soon  follow.  A case  similar  is 
recorded  by  Dr  Duke.f 

The  same  species  of  changes  may  take  place  in  the  submaxillary 
and  sublingual  glands,  though  in  these  they  have  probably  attract- 
ed less  attention.  A peculiar  cause  of  enlargement  of  the  sub- 
maxillary gland  is  the  irritation  of  teething,  and  especially  the 
presence  of  carious  molar  teeth  ; and  both  these  and  the  sublingual 
glands  may  become  enlarged  from  the  irritation  of  the  gastro-in- 
testinal  mucous  membrane  in  disorders  of  the  alimentary  canal. 
These  disorders  cause  sour  offensive  exhalations  to  arise,  indicating 
the  bad  sort  of  chyle  prepared.  The  blood  is  consequently  in  an 
unhealthy  state ; and  this,  again,  appears  to  irritate  the  glands,  and 
to  excite  their  vessels  to  increased  and  disordered  action. 

In  adults,  a common  cause  of  enlargement  of  the  parotid  and 
the  other  salivary  glands  is  the  use  of  mercury  in  strumous  habits. 
Whether  it  be  that  mercury  operates  always  hurtfully  in  the  stru- 

* Memoii-es  de  I’Academie  des  Sciences,  1760. 

t Provincial  Medical  and  Surgical  Journal,  No.  XXI,  Feb.  19,  1842. 


820 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


mous,  or  whether  it  be,  that  while  it  is  taken,  the  individuals  are 
incautious,  and  expose  themselves  to  cold,  or  commit  errors  in 
diet,  certain  it  is,  that  in  the  great  majority  of  cases,  the  first  en- 
largement of  the  parotid  and  other  salivary  glands  takes  place 
either  during  a course  of  mercury,  or  soon  after  it  is  completed. 
All  these  glands  are  more  or  less  swelled,  sometimes  very  much ; 
and  the  parotid  being  placed  in  a situation  so  conspicuous,  forms  a 
large  bulging  tumour  on  one  or  both  sides  of  the  jaw.  These  tu- 
mours are  manifestly  of  the  strumous  character,  and  occur  princi- 
pally in  strumous  subjects.  Often  they  cause  suppuration  of  the 
surrounding  cellular  tissue  and  skin,  forming  sinuous  ulcers,  and 
leaving  ugly  scars.  * 

§ 3.  The  sublingual  glands  are  liable  to  a peculiar  enlargement, 
generally  of  a chronic  character,  immediately  beneath  the  tongue, 
where  its  pressure  on  the  sublingual  veins  causes  great  dis- 
tension of  these  vessels.  To  this  appearance  a peculiar  name, 
that  of  Ranula,  has  been  applied,  from  some  fancied  resemblance 
to  a small  frog.  The  matter  causing  this  tumour  varies.  Some- 
times it  is  a simple  enlargement  of  the  gland.  More  frequently, 
however,  it  arises  from  one  or  more  concretions  in  the  excretory 
duct  of  one  or  other  of  these  glands. 

§ 4.  Chronic  induration  is  liable  to  affect  either  or  all  of  the  sa- 
livary glands.  The  change  has,  however,  been  most  commonly  ob- 
served in  the  parotid  gland.  The  gland  is  enlarged,  hard,  indo- 
lent, resistent ; and  constrains  the  motions  of  the  jaw.  Sometimes 
the  tumour  is  irregular  on  the  surface;  in  other  instances  it  is 
smooth.  As  to  pain,  evidence  varies  a good  deal ; for  in  some  in- 
stances there  is  much  deep-seated  lancinating  or  darting  pain  ; in 
others  no  pain  is  felt,  except  that  resulting  from  pressure  and  dis- 
tension of  the  parts. 

Almost  all  these  tumours  in  the  site  of  the  parotid,  if  a little 
hard,  have  been  comprehended  under  the  general  and  comprehen- 
sive name  of  scirrhus ; and  at  present  it  cannot  be  said  that  there 
is  any  good  diagnosis  between  simple  chronic  induration  and  scir- 
rhus, before  at  least  the  tumour  has  been  removed  and  subjected  to 
proper  microscopic  examination.  Boyer  himself  admits  the  diffi- 
culty of  the  diagnosis,  and  allows  that  many  cases  of  enlargement 
in  this  region,  which  were  strumous,  were  ascribed  to  scirrhus.  T 
think  it  scarcely  possible  to  mistake  for  scirrhus,  as  he  seems  to  be- 
lieve was  done,  mere  strumous  swellings,  whether  of  the  parotid 


PAROTID  GLAND — CHRONIC  INDURATION. 


821 


gland  or  of  the  lymphatic  glands,  when  taking  place  in  young  per- 
sons ; and  the  age  of  the  patient,  as  well  as  the  appearance  of  the 
tumour  and  aspect  of  the  patient,  ought  to  be  taken  into  account. 
Neither  does  mobility  avail  so  much  as  M.  Boyer  seems  to  imagine. 
A mere  indurated  parotid  gland  may,  from  its  position,  contract 
very  firm  adhesions  with  the  contiguous  parts. 

The  circumstance  of  age,  however,  must  not  be  taken  alone. 
Sabatier  records  a case  of  considerable  enlargement  in  the  site  of 
the  right  parotid,  in  a person  above  60  years.  The  tumour  extend- 
ed in  the  vertical  direction  from  the  infra-zygomatic  fossa  to  5 or  6 
centimetres  below  the  angle  of  the  jaw ; and  in  the  horizontal,  from 
the  lobe  of  the  ear  to  the  anterior  margin  of  the  temporal  muscle. 
In  shape  it  was  irregular.  It  was  free  from  pain.  To  this  tumour, 
which  Sabatier  removed  by  operation,  he  applies  the  name  of  Exu- 
berance. Upon  its  inner  structure  he  gives  no  details.  But  it 
must  have  been  an  instance  either  of  hypertrophy,  or  some  change 
difierent  from  scirrhus. 

What,  then,  is  to  be  said  of  the  cases,  now  numerous,  in  which 
the  parotid  gland  is  recorded  to  have  been  removed  by  operation  ? 
For  a long  series  of  years,  surgical  authors  have  been  in  the  habit 
of  speaking  familiarly  of  scirrhus  of  the  parotid  gland,  and  of  the 
removal  of  the  gland  for  this  distemper.  It  appears,  indeed,  at  one 
time,  if  we  form  a judgment  from  the  frequency  of  instances  of  exci- 
sion, to  have  been  imagined  to  be  a common  disease.  Thus  Heister, 
Von  Siebold,  Souscrampes,  Orth,  Burgras,  Hezel,  and  Alix,  all 
record  cases,  which,  they  say,  are  examples  of  excision  of  the  parotid 
gland. 

To  the  question  here  suggested  two  answers  must  be  given.  First, 
it  appears  certain  that  scirrhus  is  by  no  means  so  frequent  as  has 
been  supposed;  and,  secondly,  the  alleged  instances  of  scirrhus, 
from  which  the  gland  is  stated  to  have  been  removed,  were  cer- 
tainly either  strumous  indurations  and  enlargements  of  other  parts, 
or  affections  of  the  gland  not  scirrhous. 

In  several  instances  these  operations  could  not  have  been  per- 
formed on  the  gland,  and  must  have  taken  place  on  enlarged  lym- 
phatic glands ; and,  in  other  respects,  it  is  more  than  doubtful  that 
the  parotid  was  affected  by  scirrhus.  Richter  and  John  Bell  first ; 
and  afterwards  Murat,  Richerand,  Boyer,  Velpeau,  and  the  majo- 
rity of  well-informed  surgeons,  maintain  that  it  is  impossible  to  ex- 
tirpate the  gland  without  tying  the  carotid. 


822 


GENERAL  AND  PATHOLOGICAL  ANATOIIY. 


In  the  museum  of  the  College  of  Surgeons  of  Dublin,  are  seve- 
ral preparations  of  tumours  removed  either  from  the  site  or  the 
substance  of  the  parotid.  A.  a 80  is  one  from  the  substance  of 
the  parotid  gland.  It  is  about  the  size  of  a turkey’s  egg ; and  it 
was  contained  in  a fibrous  cyst,  which  adhered  to  the  substance  of 
the  gland.  Its  texture  is  in  some  parts  fibrous  and  dense ; in  others 
it  presents  patches  of  gelatinous  consistence ; and  in  one,  in  spots 
near  the  surface,  these  patches  are  soft  and  bloody.  This  had  not 
recurred  12  years  after  operation.  This  tumour  was  not  in  the 
parotid,  but  only  touching  it. 

A.  a 81  is  the  section  of  a tumour,  about  3 inches  long,  lobu- 
lated,  firm,  and  pale  in  colour,  which  was  contained  within  a cyst, 
and  was  imbedded  in  the  parotid  gland. 

A.  a 82  is  a tumour  of  the  parotid,  in  an  aged  female,  supposed 
to  be  scirrhous.  The  texture  of  the  gland  is  involved.  This  ap- 
pears to  have  been  removed  after  death. 

A.  a 83  is  a tumour  removed  by  Mr  R.  Power  from  the  parotid 
region  of  a married  female,  aged  40.  The  disease  had  commenced 
nine  years  previously,  by  a hard  swelling  about  the  size  of  a pea, 
near  the  left  angle  of  the  jaw. 

At  the  time  of  admission  to  hospital  the  tumour  was  large ; oc- 
cupying the  external  part  of  the  parotid  gland,  displacing  the  lobe 
of  the  ear,  extending  upwards  as  high  as  the  zygoma,  and  back- 
wards to  the  sterno-mastoid  muscle.  It  was  hard  and  resisting  to 
the  touch,  and  in  the  fixed  condition  of  the  jaw,  slightly  moveable. 
The  tumour  was  the  seat  of  sharp  tingling  pain,  and  caused  conside- 
rable difficulty  in  mastication.  Other  symptoms  were  pain  in  the  left 
eye-ball,  with  dimness  in  vision  and  internal  squinting;  numbness 
and  soreness  of  the  left  side  of  the  face ; impairment  of  articula- 
tion and  of  the  sense  of  taste,  with  atrophy  of  the  left  half  of  the 
tongue,  which,  when  protruded,  was  drawn  to  that  side.*  The  tu- 
mour was  easily  removed  by  operation. 

The  tumour  consists  of  two  globular  masses,  unequal  in  size. 
The  large  portion  is  firm  and  heavy,  presenting  on  section  the 
compact  hard  texture  of  scirrhus  with  radiating  fibrous  bands, 
with  slight  softening  at  one  or  two  points.  The  small  tumour  con- 

* This  statement  is  not  quite  intelligible.  If  the  tong-ue  were  drawn  to  the  left 
side,  in  which  the  tumour  was  situate,  it  shows  that  the  right  side  was  paralysed.  It 
ought,  according  to  all  that  is  known,  to  have  been  the  left  side  that  was  paralysed  ; 
and  the  tongue  would  then  have  been  drawn  to  the  right  side.  The  mistake  may  be 
clerical. 


PAEOTID  GLAND — TUMOURS  INYOLVING. 


823 


tains  softer  substance,  not  unlike  medullary  matter,  which  seems 
deposited  in  cells,  with  hard  points  interspersed,  which  had  not  yet 
lost  their  original  scirrhous  character.  A portion,  only  of  the  pa- 
rotid gland  was  removed,  and  that  portion  is  incorporated  with  the 
anterior  edge  of  the  tumour,  and  most  intimately  connected  with 
it.  The  disease  is  supposed  to  have  commenced  in  the  lymphatic 
gland  always  situate  in  this  position,  and  to  have  secondarily  affect- 
ed the  parotid  gland.* 

In  1805,  Dr  John  M'Lellan  of  Green  Castle,  Franklin  County, 
Pa.,  removed  from  the  parotid  region,  in  a female  of  50,  a tumour 
large  and  ulcerated,  believed  to  be  affected  with  carcinoma.  He 
tied  the  maxillary  and  temporal  arteries.f 

The  gland,  moreover,  has  been,  when  affected  hy  melanosis^  re- 
moved entirely  by  Dr  Mott  of  New  York.J 

M.  Larrey  is  stated  to  have  extirpated  the  parotid  gland  in  a 
young  man  of  19  for  scirrhus.  I have  no  doubt  that  this  was 
mere  strnmous  induration.§ 

In  1842,  M.  Jobert  stated  to  the  Royal  Academy  of  Medicine 
that  an  American  physician  extirpated,  in  a man  of  62,  a large 
tumour  in  the  parotid  region,  believed  to  be  affected  with  scirrhus. 
The  carotid  artery  was  in  this  case  tied.|| 

In  1842,  Dr  Wheeler  of  Dundaff,  Susquehanna,  removed  from 
the  parotid  region  of  a man,  age  not  mentioned,  a tumour  of  con- 
siderable size,  stated  very  confidently  to  be  scirrhous  in  texture, 
and  to  affect  the  whole  parotid  gland.  The  external  carotid  artery 
was  tied.  IF 

Professor  Vanzetti  of  Karahoff  (Russia)  removed  from  the  paro- 
tid region  of  a man  aged  40,  a tumour  weighing  three  pounds  and 
a-half.**  j 

From  the  facts  now  recorded,  it  can  by  no  means  be  confidently 
inferred  that  in  all  these  cases  the  parotid  gland  was  affected  with 

* Descriptive  Catalogue  of  Preparations  of  the  Museum  of  the  College  of  Surgeons 
in  Ireland.  Vol.  ii.  Dublin,  1840.  P.537. 

+ Case  of  Extirpation  of  Parotid  Gland.  American  Journal  of  Medical  Sciences, 
April  1844.  No.  XIV.  New  Series,  p.  499. 

J Case  of  Extirpation  of  the  Parotid  Gland,  by  Valentine  Mott,  M.  D.  American 
Journal  of  Medical  Sciences,  Vol.  x.  p.  17.  1832. 

§ Examinateur  Medicale,  15th  Aug.  1841. 

II  Archives  Generates,  Illieme  Serie.  Tome  LX.  p.  232.  Oct.  1842. 

IT  Extirpation  of  a Scirrhous  Parotid  Gland.  By  H.  H.  Wheeler,  M.  D.  Ameri- 
can Journal  of  Medical  Sciences,  No.  XVIII.  April  1845,  520. 

**  Annales  de  Chirurgie.  Aout  1844. 


824 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


scirrhus.  Two  inferences  seem  to  be  established  by  the  cases  now 
noticed.  The  first  is,  that  these  tumours  are  not  in  all  cases  seated 
in  the  parotid  gland.  In  the  majority  of  cases  they  do  not  at  first 
affect  the  gland,  which  is  involved  only  secondarily.  Most  com- 
monly they  are  seated  in  lymphatic  glands  or  cellular  tissue.  The 
second  inference  is,  that  the  tumours  of  the  kind  now  noticed  cannot 
in  all  cases  be  regarded  as  scirrhous.  It  is  quite  impossible  to  ad- 
mit that  the  tumour  in  the  young  person  of  19  w^as  scirrhus;  and 
as  to  the  others,  there  is  no  very  certain  evidence  that  these  tu- 
mours are  any  thing  but  strumous  glands  or  swellings. 

It  appears,  nevertheless,  that  these  glands  are  liable  to  be  in- 
volved in  the  morbid  changes  and  growths  so  frequently  observed 
in  this  region. 

Lastly,  it  must  be  allowed  that  the  most  frequent  change  ob- 
served in  the  salivary  glands,  and  perhaps  in  all  glands,  is  that 
of  induration,  {sMeroma\  in  consequence  of  the  eflPusion  of  plastic 
matter  during  chronic  and  strumous  inflammation,  either  around 
their  component  granules  or  within  these  granules. 

§5.  The  parotid  gland  is  liable  to  the  formation  of  other  structures 
besides  induration  and  scirrhus.  Mr  Pole  records,  in  the  person 
of  a woman  of  47,  an  instance  in  which  a tumour  began  to  be  form- 
ed in  the  site  of  the  left  parotid  gland  about  1 1 years  previously. 
This  tumour  steadily  and  progressively  increased  in  size,  aflfecting 
also  the  submaxillary  glands,  until  it  caused  death  by  suffocation, 
by  compressing  the  trachea,  oesophagus,  and  blood-vessels.  After 
death,  when  it  was  removed,  it  weighed  ten  pounds  and  a half; 
and  contained  every  kind  of  substance  which  usually  fills  steatoma, 
meliceris,  atheroma,  lipoma,  and  even  carcinoma,  enclosed  in 
cysts.* 

Similar  to  this,  though  observing  an  inverted  order  in  succession, 
is  the  case  given  by  Cheselden,  who  shortly  states,  that  he  was  pre- 
sent at  the  inspection  of  a woman  who  was  suffocated  by  a tumour 
which  began  in  the  submaxillary  gland,  and  extended  itself  from 
the  sternum  to  the  parotid  gland  in  six  weeks  time,  and  in  nine 
weeks  killed  her.  It  was  a true  scirrhus,  he  adds,  and  weighed 
twenty-six  ounces.f 

* A Case  of  Extraordinary  Diseased  Enlargement  of  the  Parotid  and  SubmaxilJary 
Glands.  By  T.  Pole,  Surgeon.  Memoirs  of  Medical  Society,  Vol.  iii.  p.  546.  Lon- 
don, 1792. 

t The  Anatomy  of  the  Human  Body.  London,  1784,  p.  143. 

3 


PAROTID  GLAND — TUMOURS  INVOLVING. 


825 


It  does  not  impugn  much  the  judgment  of  this  excellent  surgeon, 
if  we  doubt  whether  this  tumour  were  a true  scirrhus.  If  it  were 
not  malignant,  it  might  have  been  a mere  strumous  enlargement. 
If  it  were  malignant,  it  was  much  more  likely  to  be  encephaloid 
disease  than  scirrhoma. 

But  even  this  point  it  is  very  difficult  to  determine.  In  most 
cases  of  tumours  affecting  the  neck,  the  enlargement  consists  either 
in  strumous  disorder  of  the  lymphatic  glands,  affecting  probably 
also  the  salivary  glands ; or  in  encephaloma^  affecting  these  glands 
and  the  cellular  tissue. 

A woman  of  about  40,  with  a tumour  on  the  right  side  of  the 
neck,  extending  from  the  parotid  region  downwards  to  the  collar 
bone  and  larynx,  was  admitted  into  the  Royal  Infirmary.  The 
tumour  was  lobulated,  and  consisted  of  seven  or  eight  spheroidal 
masses.  It  might  have  affected  the  parotid  gland,  the  site  of  which 
it  covered ; and,  as  it  dipped  under  the  angle  of  the  jaw,  it  might 
also  have  involved  the  submaxillary.  It  was,  nevertheless,  ob- 
vious from  its  lobulated  encysted  appearance,  and  the  short  time 
which  had  elapsed  since  its  commencement,  that  it  was  probably 
encephaloid.  It  was  removed  with  great  dexterity  and  success  by 
an  able  surgeon ; though  it  was  found  requisite  to  enclose  in  a li- 
gature a portion  which  descended  deep  near  the  articulation  of  the 
lower  jaw. 

The  tumour  consisted  of  about  12  or  13  spherical  masses,  each 
enclosed  in  a separate  cyst.  The  matter  contained  in  these  cysts 
was  of  a whitish-gray  colour,  of  the  consistence  between  fat  and  gra- 
nular cheese,  and  in  all  respects  resembling  the  encephaloid  growth. 
It  was  impossible  to  detect  the  substance  of  the  parotid  gland, 
which  seemed  to  be  involved  in  this  growth,  and  was  otherwise 
rendered  indistinct  by  the  last  incisions. 

The  wound  healed  up  well.  But  about  three  months  after,  the 
disease  returned  and  destroyed  the  patient. 

This  must  be  regarded  as  either  a case  of  encephaloma,  affecting 
first  the  lymphatic  glands  and  cellular  tissue  of  the  neck,  and  after- 
wards, perhaps,  the  parotid  gland,  or  as  an  instance  of  the  tumour 
called  cystic  sarcoma. 

The  salivary  glands  are  liable  to  the  formation  of  encysted  tu- 
mours. Sandifort  mentions  one  being  found  in  the  parotid  gland. 

The  observations  hitherto  made  are  applicable  to  the  submaxil- 
lary and  sublingual  glands,  as  well  as  to  the  parotid.  Both  the 


826 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


submaxillary  and  sublingual  glands  are  liable  to  be  affected  by  in- 
flammation, more  frequently  chronic  than  acute.  This  process 
causes  hard  swellings,  with  more  or  less  pain,  in  the  site  of  these 
glands. 

§ 6.  Occlusion  of  Ducts. — More  or  less  obstruction  of  the  excre- 
tory ducts  is  a disorder  common  to  all  glands.  This  may  be  occa- 
sioned either  by  the  ducts  being  contracted  and  narrowed  by  in- 
flammatory thickening  or  its  products,  or  by  some  of  the  products 
of  secretion  sticking  in  the  ducts. 

The  ducts  in  which  changes  of  this  kind  are  most  usually  ob- 
served are  Steno’s  ducts  in  the  parotid,  and  Wharton’s  in  the  suh- 
maxillary  and  the  sublingual  ducts.  There  is  no  doubt,  neverthe- 
less, that  the  lacrymal  excretory  ducts  are  liable  to  the  same  in- 
convenience. 

When  the  duct  of  Steno  is  obstructed  by  any  cause  of  the  kind 
now  referred  to,  a swelling  more  or  less  considerable,  and  more  or 
less  firm,  is  formed  in  its  course,  in  the  cheek ; and  unless  the  ob- 
structing cause  is  removed,  it  sometimes  produces  ulceration  of  the 
walls  of  the  duct,  and  salivary  fistula. 

The  same  accident  may  happen  to  the  duct  of  Wharton.  Of  this 
sort  of  swelling,  Boyer  saw  an  instance.  The  gland  swelled,  and 
the  swelling  subsided  alternately,  as  the  saliva  was  retained  or  was 
allowed  to  flow  into  the  mouth.  By  pressing  the  tumour  whenever 
the  pain  allowed  pressure  to  be  made,  the  saliva  was  urged  along 
the  duct  into  the  mouth,  and  the  volume  of  the  gland  diminished. 
This  condition  continued  for  months.  Boyer  recommended  the 
patient  to  make  frequent  and  long-continued  use  of  mallow  water 
in  the  mouth.  The  swelling  of  the  walls  of  the  canal  subsided ; 
the  saliva  resumed  its  free  course  ; and  the  gland  no  longer  swell- 
ed. 

§ 7.  Concretions. — The  most  usual  causes,  however,  probably,  of 
obstructions  are  the'presence  of  concretions  in  the  excretory  ducts. 
This  cause  is  common  to  all  glands ; for  the  secreted  product  may 
be  prevented  from  descending  along  the  ducts,  either  hy  its  own 
viscidity  and  morbid  consistence,  or  by  some  arctation  in  the  ducts. 

All  excreting  ducts  are  liable  to  have  their  channels  contracted 
by  tbickening  of  the  walls.  But  independent  of  this  cause,  which 
has  been  already  noticed,  the  secretions  of  all  glands,  though  ori- 
ginally and  normally  fluid,  are  liable  to  vary  in  chemical  and  me- 
chanical properties,  and  thereby  to  favour  the  formation  of  various 


LACRYMAL  AND  SALIVARY  GLANDS — CONCRETIONS.  827 


solid  masses.  Thus  concretions  are  found  to  affect  the  lacrymal 
and  salivary  glands,  as  well  as  the  hepatic  and  renal  ducts. 

§ 8.  Lacryjial  Concretions.  Dacryolitha. — Concretions  or 
hard  bodies  formed  in  the  lacrymal  gland,  or  its  ducts,  have  been 
noticed  and  recorded  by  many  authors.  Schurig  relates  from  Paul- 
lin  the  fact,  that,  in  a young  peasant,  along  with  the  tears  small 
stones  were  discharged,  with  heat,  itching,  and  pain.*  Lachmund 
relates,  that  in  1661,  in  a girl  of  13,  there  arose  a painful  swelling 
on  the  left  temple,  from  which,  as  well  as  from  the  angle  of  the  eye, 
were  discharged  small  stones  at  intervals  for  the  space  of  three  weeks. f 
Similar  cases  are  mentioned  as  having  occurred  to  d’Emery,^  Schafer,§ 
and  Plot.  II  An  important  case  is  given  by  Walther.  In  a healthy 
young  woman,  from  the  left  upper  eyelid  in  whom,  two  years  pre- 
viously a portion  of  chalky  matter  had  been  removed,  without  leav- 
ing any  bad  effect,  there  were  formed,  amidst  evident  marks  of  in- 
flammation, recurring  from  time  to  time,  in  the  fold  between  the 
eye-ball  and  the  lower  eye-lid,  opposite  the  external  angle  of  the 
eye,  white  angular  stones  of  thfi  size  of  a pea,  which,  in  the  subse- 
quent course  of  the  disease,  became  more  numerous  and  larger. 
After  some  time  the  left  eye  was  first  delivered  from  the  evil.  But 
a similar  formation  of  concretions  began  in  the  right  eye  at  the 
same  place.  The  phenomena  progressively  diminished,  and  at 
length  ceased;  yet  returned  after  some  years  in  a milder  form. 
At  length  the  patient  got  quite  well.lf  Guillie  mentions  that,  in  a 
young  person  of  15,  after  marks  of  violent  inflammation,  with  red- 
ness and  swelling  of  the  eye-lids,  the  lower  fold  of  the  conjunctiva 
was  filled  on  the  6th  day  with  chalky  deposit  like  fine  sand ; and 
on  the  9th  day  there  appeared  at  the  outer  angle  a small  co- 
nical-shaped body,  as  thick  as  a vetch,  reddish  yellow,  and  irregu- 
lar on  the  surface,  which  was  loosely  attached  to  the  conjunctiva, 
and  was  easily  removed  by  forceps.** 

Dr  Kersten,ft  who  writes  an  elaborate  paper  on  these  concretions, 

* Schurig  Lithologia,  p.  100.  f De  Fossilibus,  Sect.  iii.  Cap.  22,  p.  72. 

J Journal  des  Sfavans,  1679,  1 May,  p.  66-68. 

§ Ephemerid.  Cent.  iii.  iv.  Obs.  clxxvii.  p.  421. 

II  Natural  History  of  Oxfordshire.  London,  1677.  Folio. 

f Graefe  und  Walther’s  Journal,  Band  i.  Heft  i.  S.  163. 

**  Bibliotheque  Ophthalmologique,  Tome  i.  p.  1 33. 

Ueber  Steinerzeugung  aus  der  Thranenflussigheit,  Von  Dr  Kersten  in  Mag- 
deburg. C.  W.  Hufeland’s  J ournal  der  Practischen  'Heilkunde.  Fortgesetzte  von  Dr 
Fr.  Busse.  1843.  iv.  u.  v.  Stuck  April  u Alay,  xcv.  Band  4 u 5 St.  S.  26-63. 


828 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


thinks,  that  they  may  be  formed  in  the  caruncula  lacryrnalis ; and 
he  believes  that  they  are  formed  also  in  the  puncta,  the  canal,  and 
sac.  This  seems  very  doubtful  as  a general  inference.  These  con- 
cretions appear  generally  at  the  outer  angle  of  the  orbit ; and  it  is 
most  likely,  that  they  are  most  commonly  formed  in  the  ducts  and 
orifices  of  the  lacrymal  gland,  or  near  this  situation. 

Sandifort,  however,  found  concretions  in  the  lacrymal  canal ; 
and  Desmarres  records  the  circumstances  of  a case  in  which,  in  a 
gouty  female  of  66,  he  found  a lacrymal  concretion  impacted  in 
the  lacrymal  sac  of  the  right  side.  Manifest  swelling  was  formed 
over  the  inner  angle  of  the  right  eye.  The  patient  had  suffered 
for  two  years  from  lacrymation,  and  latterly  a discharge  of  matter 
from  the  eye.  The  lower  punctum  was  enlarged  to  three  times  its 
normal  size.  In  the  course  of  the  lower  lacrymal  duct  there  was 
a small,  prominent,  circumscribed,  indolent,  and  colourless  swell- 
ing. By  means  of  a probe,  Desmarres  recognized  the  presence  of 
a solid  body.  He  then  introduced  a grooved  probe,  and,  dividing 
the  integuments  down  to  the  canal,  he  extracted  a hard,  yellowish, 
pea-like  body.  The  wound  was  healed  in  24  days.* 

On  the  frequency  of  the  occurrence  of  concretions  in  the  lacry- 
mal sac  evidence  is  divided.  While  some  authors,  as  Nicolai  and 
Waldeck,  consider  the  lacrymal  sac  as  the  most  usual  place  for  the 
formation  of  lacrymal  concretions,  others,  viz.  Walther,  maintain 
that  they  are  never  found  in  this  receptacle.  That  this  is  a mis- 
take is  evident  from  cases  recorded  by  Le  Dran,  Schmucker,  Kri- 
mer,  Cunier,  Stievenart,  Thibou,  and  Maunoir. 

Cunier,  in  particular,  gives  the  details  of  two  cases,  one  in  a man, 
of  58,  another  in  one  of  63,  in  which  concretions  were  found  in 
this  situation,!  and  which  seem  to  leave  no  doubt  of  the  fact. 

Lacrymal  concretions  of  the  largest  size  are  observed  in  the 
nasal  duct ; because  in  the  cavity  of  this  canal  there  is  most  space 
for  their  growth  and  enlargement  with  least  inconvenience.  Of 
this  three  examples  are  recorded ; two  in  the  observations  of  Dr 
Kersten,  and  one  by  Horn  in  Schmucker ’s  Miscellaneous  Writ- 
ings. 

It  may  be  observed  that  though  these  concretions  occur  some- 
times in  young  persons,  yet  in  general  their  subjects  are  of  middle 
age  or  up  in  years,  and  persons  who  have  suffered  from  gout  and 
Aimales  d’Oculiste.  Paris,  1842. 

t Observations  pour  servir  a I’histoire  cles  Calculs  Lacrymales.  Bruxelles,  1842. 


LACRYMAL  AND  SALIVARY  GLANDS — CONCRETIONS.  829 


rheumatic  symptoms.  In  one  of  the  instances  given  by  Cunier, 
the  patient  had,  six  years  previously,  viz.  in  1831,  been  cut  for 
stone  in  the  bladder  by  Dupuytren. 

Lacrymal  concretions  have  been  analyzed  at  different  times  by 
different  persons,  uchs  found  in  the  concretions  given  him  by 
Walther  carbonate  of  lime,  forming  the  largest  part  of  the  weight, 
and  traces  of  phosphate  of  lime  and  albumen.  The  concretions 
met  with  by  Cunier  consisted  chiefly,  according  to  Pasquier,  of  car- 
bonate of  lime,  with  traces  of  phosphate  of  lime  and  muriate  of 
soda ; and  in  one  there  was  some  phosphate  of  magnesia.  Lastly, 
the  concretion  removed  by  Desmarres  was  analysed  by  Bouchar- 
dat  and  gave  the  following  results ; — solid  albuminous  matter,  25 
parts;  mucus,  18  parts;  carbonate  of  lime,  48  parts;  phosphate  of 
lime  and  magnesia,  9 parts ; with  traces  of  fat  and  muriate  of  soda.* 

These  facts  seem  to  justify  the  views  taken  by  Walther,  Cunier, 
and  Desmarres,  that  the  formation  of  lacrymal  concretions,  like 
that  of  other  concretions,  depends  on  general  causes. 

Lacrymal  concretions  are  perhaps  disposed  to  be  formed  more 
readily  from  the  complexity  and  tortuosity  of  the  lacrymal  pas- 
sages, and  also  from  their  narrowness  and  liability  to  inflammatory 
thickening  and  obstruction. 

Salivary  concretions  have  not  quite  so  frequently  been  observed 
as  lacrymal  concretions.  They  are  nevertheless  by  no  means  un- 
common. 

The  most  usual  situation  for  salivary  concretions  to  be  present- 
ed are  either  beneath  the  tongue  in  the  ducts  of  the  sublingual 
glands,  or  in  the  duct  of  Wharton  leading  from  the  submaxillary 
gland. 

In  the  former  situation  the  cases  are  so  numerous,  that  it  is  im- 
possible in  this  place  to  enumerate  the  twentieth  part  of  them.  I 
shall  merely  mention  that  instances  of  salivary  concretions  have 
been  recorded  by  Lister,  Freeman,  Scherer,  (1737);  Bacciocchi, 
(1749);  Hamberger,  (1754) ; Handtwig,  (1754) ; Hartmann, 
(1762  and  1784) ; Heilman  (apud  von  Siebold,)  Titius,  and  seve- 
ral others. 

Most  of  these  are  from  the  ducts  of  the  sublingual  gland.  Fla- 
jani  gives  a case  of  calculus  from  Steno’s  duct,  which  is  the  least 
frequent.  Since  the  time  of  Flajani  cases  have  been  recorded  by 
* Annales  d'Oculiste.  Paris,  1842. 


830 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Muller  (1811)  and  Seguignol.  In  the  cases  by  Scherer,  Acrel, 
Heilman,  in  one  by  Sabatier,  and  in  one  by  Boyer,  the  concretions 
were  from  the  duct  of  Wharton. 

In  the  first  case,  these  concretions  give  rise  to  an  irregular  swell- 
ing beneath  the  tongue,  and  form  one  variety  of  the  disease  named 
ranula.  The  size  of  this  swelling  varies  according  to  the  size  of 
the  stone,  and  may  be  from  that  of  a pea  to  the  size  of  a filbert,  or 
even  a walnut.  In  some  rare  instances  they  give  rise  to  inflamma- 
tion and  ulceration,  and  thus  extricate  themselves  from  the  position 
in  which  they  are  confined.  More  frequently,  however,  they  re- 
quire the  aid  of  operation.  In  the  case  given  by  Sabatier,  it  ap- 
pears that  the  presence  of  the  concretion  in  the  duct  of  Wharton 
caused  painful  swelling  of  the  suhmaxillary  gland,  and  this  seems 
to  have  given  rise  to  more  suffering  and  inconvenience  than  the 
immediate  swelling  caused  by  the  tumour.  Two  concretions  were 
in  this  case  removed  by  two  separate  and  successive  operations.* 
Boyer  tells  us  that  in  a similar  case  in  which  the  suhmaxillary 
gland  was  likewise  swelled,  he  cured  the  swelling  of  the  gland  by 
extracting  an  oblong  stony  concretion,  one  extremity  of  which 
projected  a little  beyond  the  orifice  of  the  duct  of  Wharton. 

I may  here  mention  that  salivary  concretions  are  occasionally  found 
in  the  lower  animals.  Grognier  records  two  cases  of  this  lesion. 
In  one  a concretion  weighing  6 drachms  was  found  in  the  Steno- 
nian  duct  of  a mule ; in  another  a concretion  weighing  1 3 drachms 
was  found  in  the  Stenonian  duct  of  an  ass.f 

The  chemical  constitution  of  these  concretions  has  been  several 
times  examined.  They  consist  of  carbonate  and  phosphate  of  lime 
coated  with  animal  matter,  with  traces  of  muriate  of  soda, 

§ 9.  Ranula. — Of  this  disease  it  would  be  unnecessary  to  say  any 
more,  were  the  terms  not  employed  to  designate  more  than  one 
morbid  affection.  To  every  tumour,  in  short,  appearing  beneath 
the  tongue,  the  denomination  of  ranula  is  given.  Munnicks,  Louis, 
and  after  him  Boyer,  espoused  the  opinion  that  the  swelling  de- 
pended on  an  accumulation  of  saliva  in  the  duct  of  Wharton. 
But  the  main  point  was,  why  did  the  saliva  accumulate  ? Boyer 
was  of  opinion  that  this  was  caused  by  obstruction  at  the  outlet  of 
the  ducts,  or  obliteration  of  those  outlets.  In  point  of  fact,  there 

* Sabatier,  Medecine  Operatoire. 

-j-  Grognier  in  Sceance  de  I’Ecole  Veterinaire.  Journal  de  Medecine  continue, 
1810,  Dec.  p.  504. 


INFLAMMATION  OF  THE  PANCREAS. 


831 


is  no  doubt  that,  from  various  causes,  most  frequently  inflammatory 
thickening,  the  duct  is  narrowed,  and  its  outlet  is  either  obstructed 
or  temporarily  obliterated.  Even  inflammation  of  the  mucous 
membrane  of  the  mouth,  by  causing  obliteration  of  the  outlets  of 
the  duct,  may  be  followed  by  such  accumulation.  In  other  in- 
stances, again,  the  presence  of  a calculus  within  any  of  the  ducts 
has  the  same  efiect. 

Ranula  is  said  to  appear  in  the  form  of  a tumour,  in  some  de- 
gree transparent,  soft,  and  fluctuating,  and  in  some  instances  in  the 
form  of  one  quite  hard  and  firm.  At  first  small,  it  gradually  en- 
larges, projecting  into  the  mouth,  and  interfering  much  with  mas- 
tication, speech,  and  even  deglutition.  It  is  even  said  that  the 
eflFect  on  speech  is  so  considerable,  as  to  make  the  voice  of  the  pa- 
tient resemble  the  croaking  of  frogs,  and  that  from  this  circum- 
stance the  disease  receives  its  name.  This  is  probably  an  idle 
fancy. 


Section  III. 

DISEASES  OF  THE  PANCREAS. 

The  diseases  of  the  pancreas  may  be  enumerated  in  the  follow- 
ing order.  1.  Inflammation  and  its  effects,  adhesion,  and  suppu- 
ration ; 2.  simple  induration  ; 3.  chronic  induration  ; 4.  hypertro- 
phy ; 5.  softening  ; 6.  atrophy ; 7.  concretions  in  the  ducts  or  duct ; 
8.  chronic  ulceration ; and  9.  the  heterologous  deposits. 

§ I.  INFLAMMATION  OF  THE  SWEATBREAD  OR  PANCREAS. 

AVNCREATIA,  PANCREATITIS. 

That  the  pancreas  is  liable  to  inflammation  has  been  admitted 
by  most  morbid  anatomists ; but  it  has  been  also  ascertained,  that 
it  is  very  difficult,  if  not  impracticable,  to  recognize  the  inflamed 
state  of  the  gland  by  symptoms  during  life,  Morgagni  believed 
that  he  found  it  twice  in  a state  of  inflammation,  that  is,  redder  and 
more  vascular  than  usual;  and  Wedekind  and  Daniel  have  since 
his  time  mentioned  the  circumstance  as  taking  place  occasionally. 
Portal  states  in  general  terms  that,  when  inflamed,  it  is  redder 
than  natural  not  only  at  its  external  surface,  but  in  its  interior 
substance ; and  that  it  had  been  found  in  this  state  in  persons  who 
had  undergone  an  attack  of  continued  fever  of  more  or  less  inten- 


832 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


sity,  with  pains  in  the  abdomen,  especially  at  the  navel,  frequent 
fits  of  violent  vomiting,  in  some  instances  jaundice,  and  diminished 
secretion  of  urine.  Baillie  was  led  by  experience  to  regard  in- 
flammation as  not  very  liable  to  attack  the  pancreas. 

The  only  inference  that  can  be  deduced  from  these  several  facts, 
is,  that  inflammatory  action,  if  it  do  take  place  in  the  pancreas,  does 
not  in  all  cases  evince  its  presence  by  well-marked  or  unequivocal 
symptoms.  Does  the  inflammatory  process,  it  may  be  asked,  leave 
distinct  effects  of  its  presence  ? 

Of  the  presence  of  inflammation  in  this  gland  several  proofs  may 
be  adduced.  One  is  redness  of  the  pancreatic  substance  with 
vascularity  and  more  or  less  softness,  generally  with  effusion  of 
bloody  serum  in  the  glandular  substance  and  surrounding  cellular 
tissue.  Another  is  either  the  effusion  of  albuminous  matter  in  the 
neighbourhood,  or  preternatural  adhesion  to  the  adjoining  organs. 
A third  effect  is  suppuration  or  abscess  of  the  gland,  sometimes  with, 
more  frequently  without,  pain  and  other  external  symptoms.  And 
a fourth  consists  in  different  degrees  of  induration  of  the  gland, 
usually  with  pain  in  the  epigastric  region,  and  occasional  vomiting. 

§ 1.  Redness  and  vascularity  are  occasionally  observed  in  the  pan- 
creas. But  they  are  most  frequently  the  effect  of  transudation  after 
death,  or  some  similar  pseudo-morbid  process.  In  cases  in  which 
they  are  associated  either  with  effusion  of  plastic  exudation,  or 
purulent  matter,  or  induration  or  softening,  they  must  be  allowed 
to  depend  o»  inflammation.  This,  however,  is  not  common ; chiefly 
because  inflammation  of  the  pancreas  is  not  usually  an  acute  dis- 
ease, and  death  does  not  take  place  in  the  early  stage  of  the  dis- 
order. 

One  of  the  best  and  least  equivocal  examples  of  inflammation  of 
the  pancreas  is  given  by  Mr  Lawrence ; and  as  the  appearances 
observed  by  Mr  Lawrence  illustrate  well  the  effects  of  inflamma- 
tion, it  is  proper  to  mention  them. 

The  case  occurred  in  a married  lady  of  21,  partly  during  preg- 
nancy, and  partly  after  delivery.  During  the  three  latter  months  of 
pregnancy,  the  patient  suffered  unusually  from  thirst,  and  drank 
large  quantities  of  water.  She  had  also  suffered  much  from  pain 
in  the  epigastric  region,  particularly  over  the  site  of  the  pancreas. 
She  became  pale,  anaemic,  feeble,  and  breathless.  She  made  no 
good  recovery  after  delivery,  but  presented  symptoms  of  great 
weakness  and  exhaustion  ; and  died  exactly  five  weeks  after  delivery. 


I 


INFL.^MMATION  OF  THE  PANCREAS. 


833 


Upon  inspecting  the  body,  the  cellular  texture  round  the  pan- 
creas and  duodenum,  the  great  and  small  omentum,  the  root  of 
the  mesentery,  the  mesocolon,  and  the  appendices  epiploicce  of  the 
arch  of  the  colon,  was  loaded  with  serous  fluid,  transparent,  bright 
yellow,  and  of  watery  consistence,  which  escaped  abundantly  from 
incisions.  The  pancreas  was  throughout  of  a deep  dull  red  colour, 
which  contrasted  very  remarkably  with  the  bloodless  condition  of 
other  parts.  It  was  firm  to  the  feeling  externally ; and  when  an 
incision  was  made  into  it,  the  divided  lobules  felt  particularly  firm 
and  crisp.  The  texture  was  otherwise  healthy.  The  part  was  left 
wrapped  in  a cloth  for  nearly  forty-eight  hours  after  its  removal 
from  the  body,  when  the  weather  was  very  cold.  At  the  end  of  this 
time  the  hardness  was  gone,  and  the  gland  appeared  rather  soft.* 

From  this  it  results  that  redness,  and  vascularity,  and  slight 
hardness  followed  by  softening,  with  infiltration  of  serous  or  sero- 
albuminous  fluid,  constitute  the  anatomical  characters  of  pancreatic 
inflammation.  This  case  also  illustrates  a principle  formerly  men- 
tioned as  to  the  effects  of  inflammation,  namely,  that  the  process 
renders  the  tissues  friable  and  easily  lacerable. 

§ 2.  Adhesion  of  the  pancreas  to  the  adjoining  organs  may  he  the 
effect  either  of  suppurative  or  common  inflammation.  In  general, 
when  suppurative  inflammation  takes  place,  more  or  less  albumi- 
nous deposition  is  formed,  and  connects  the  gland  to  the  adjoining- 
organs,  either  to  prevent  the  farther  progress  of  the  destructive 
efiects  of  the  suppuration,  or  to  prevent  the  purulent  matter  from 
being  absorbed  by  the  veins  and  transported  into  the  circulating 
system. 

§ 3.  Purulent  Inflammation  of  the  Pancreas. — Collections  of  pu- 
rulent matter  in  the  pancreas  have  been  observed  by  many  anato- 
mists. Tulpius  mentions  the  case  of  a young  man  who,  after  an 
intermittent  fever,  was  attacked  with  pain  in  the  belly  and  loins, 
so  violent,  that  he  was  unable  to  lie  on  any  side.  After  death, 
besides  inflammation  of  the  liver,  the  pancreas  was  found  suppu- 
rated.f  Thomas  Bartholin  found,  in  a man  who  had  previously 
fever  with  pains  in  the  back  and  in  the  loins,  the  pancreas  alto- 
gether destroyed  by  an  enormous  abscess  full  of  foetid  greenish 

* History  of  a Case  in  which,  on  Examination  after  Death,  the  Pancreas  was  found 
in  a state  of  active  Inflammation.  By  William  La^vrence,  F.  R.  S.  Medico-Chirur- 
gical  Transactions,  Vol.  xvi.  p.  366.  London,  1830. 

t Ohs.  Med.'Lib.  iv.  cap.  xxxiii.  p.  3’27.  Amst.  16.52  and  1672. 


834 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


matter  ;*  and  Blancard  records  a similar  history  ;f  and  Lieutaud 
mentions  instances  which  had  occurred  to  various  observers.!  Bonz 
describes  in  a man  of  thirty-eight,  an  abscess  in  the  right  extremity 
of  the  pancreas,  the  purulent  matter  of  which  implicated  the  sto- 
mach and  the  liver,  and  established  a communication  between  the 
liver  and  the  abdomen.§  Gautier  states  that,  in  the  body  of  a 
woman  who  had  been  afflicted  with  long-continued  cardialgia,  he 
saw  an  abscess  of  the  pancreas  which  opened  into  the  postei'ior  w^all 
of  the  stomach.  II  Portal  states  that  he  found  the  pancreas  in  a 
state  of  complete  suppuration  in  a person  who,  after  having  expe- 
rienced violent  paroxysms  of  gout  in  the  feet,  upon  their  disap- 
pearance had  two  or  three  fits  of  vomiting,  followed  by  syncope 
and  death.^  Baillie  informs  us,  that  he  only  once  met  with  an  ab- 
scess in  the  pancreas  in  the  case  of  a young  man  of  little  beyond 
the  age  of  twenty,  and  in  whom  the  gland  was  enlarged  in  size, 
and  contained  a good  deal  of  thin  purulent  fluid  without  peculiar 
characters,  unattended  by  fixed  pain  in  the  region  of  the  gland, 
but  with  a good  deal  of  pain  in  different  parts  of  the  belly.** 

Dr  Playgarth  records  the  case  of  a gentleman  who  laboured  un- 
der jaundice,  bilious  vomiting,  and  disordered  urinary  secretion 
with  epigastric  pain  and  swelling,  and  at  length  the  discharge  of 
blood  and  purulent  matter  from  the  intestines.  After  three  months 
death  took  place.  The  pancreas  was  found  greatly  enlarged,  oc- 
cupying the  site  of  the  tumour  felt  during  life  in  the  epigastric  re- 
gion. The  common  biliary  duct  was  obliterated  where  the  pres- 
sure had  been  greatest.  The  gall-bladder  was  full  and  the  cystic 
duct  pervious.  The  substance  of  the  pancreas  was  indurated,  and 
when  divided  it  contained  a considerable  abscess.ft 

In  cases  of  this  nature  the  suppuration  may  he  either  limited 
and  partial,  or  extensive  and  destroying  the  greater  part  or  the 
whole  of  the  gland.  The  matter  is  usually  of  a gray-white  colour, 

* Centuria  ii.  Hist,  xxxix.  Tom.  i.  p.  333.  Hafniae,  1654-1657. 

f Anatom.  Pract.  Cent.  ii.  Obs.  Iv.  p.  271. 

J Hist.  Anatom.  Med.  Tom.  i.  Obs.  1046  and  1060. 

§ Nov.  Acta.  N.  C.  T.  viii.  p.  51. 

II  J.  L.  Gautier  de  Irritabilitatis  Notione,  Natura,  et  Morbis.  Halse,  1793,  § 13,  p. 
129. 

H Anatomic  Medicale,  Tom.  v.  p.  352.  Paris,  1803. 

•»*  Morbid  Anatomy  in  Works  by  Wardrop,  Vol.  ii.  p.  238  and  240.  London,  1825. 

i-f  Two  Cases  of  Inflammation  and  Enlargement  of  the  Pancreas,  &c.  Transac- 
tions of  Association,  Vol.  II.  p.  132.  Dublin,  1818. 


SUPPURATION  OF  THE  PANCREAS. 


835 


similar  to  that  of  other  abscesses ; in  a few  cases  it  is  greenish. 
It  may  be  either  inodorous  or  exhale  a faint  mawkish  odour  like 
ordinary  matter ; and  it  has  in  a few  instances  been  found  ex- 
tremely fetid.  In  some  cases  it  consists  of  thin  serous  fluid  with 
curdly  clots ; and  it  is  then  conceived  to  indicate  the  presence  of 
the  strumous  diathesis. 

The  matter  of  these  pancreatic  abscesses  is  often  enclosed  with- 
in a sac  or  membranous  pouch,  formed  by  the  cellular  tissue  either 
of  the  pancreas  or  covering  the  gland.  Portal  states  that  he  has 
seen  two  pounds  of  purulent  matter  contained  within  the  gland. 
It  may  open  a passage  to  itself  either  through  the  posterior  wall  of 
the  stomach,  through  part  of  the  duodenum^  through  the  colon  into 
its  cavity,  or  into  the  general  cavity  of  the  peritoncsum. 

Portal  allows  that  suppuration  is  in  many  cases  the  immediate 
eflfect  of  inflammation  of  the  pancreas.  It  may  be  admitted  that, 
in  all  cases  where  suppuration  has  taken  place,  it  is  the  effect  of 
inflammation ; and  the  only  circumstance  of  difference  is  the  ques- 
tion, whether  the  inflammation  is  attended  with  pain  and  other 
feelings  of  uneasiness,  or  is  unattended  by  these  symptoms  ? Sup- 
puration seems  always  to  be  a process  occupying  a considerable 
time ; and  in  this  point  of  view  it  may  be  said  to  be  chronic.  But 
it  appears  from  the  cases  recorded,  that  suppuration  or  suppurative 
inflammation  is  of  three  kinds  at  least ; the  ordinary,  the  strumous, 
and  the  metastatic.  In  the  two  former  instances,  it  must  be  ad- 
mitted to  be  preceded  by  inflammatory  action,  however  obscure 
that  may  be,  and  however  indistinct  be  the  symptoms  to  which  the 
process  gives  rise. 

It  is  chiefly  important  to  observe  that  inflammatory  suppuration 
of  the  pancreas  does  not  give  rise  to  well  marked  symptoms  at  first. 
But  after  some  time,  that  is,  when  probably  the  purulent  collection 
has  become  considerable,  and  begun  by  mechanical  pressure  and 
distension  to  affect  the  physiological  properties  of  the  gland  and 
the  contiguous  parts,  fits  of  vomiting,  more  or  less  violent  and  con- 
tinued, especially  after  taking  food,  take  place ; pains  of  the  loins, 
which  have  been  often  mistaken  for  nephritic  or  rheumatic  pains, 
and  which  prevent  the  patient  from  lying  on  his  back,  ensue ; 
sometimes  pains  of  the  belly,  like  spasmodic  pains  (Baillie),  are  ob- 
served ; after  some  time  the  pulse,  which  at  first  was  unaflPected, 
becomes  a little  quick, — from  80  to  86  ; dyspeptic  symptoms,  as  fla- 
tulence, cardialgia,  and  gastrodynia^  are  observed,  in  some  in- 


836 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


stances  with  occasional  diarrhoea  ; the  patient  appears  to  derive  no 
nutriment  from  his  food  ; and  he  dies  tabid. 

The  name  of  metastatic  suppurative  inflammation  I have  applied 
to  denote  suppuration  of  the  pancreas  occurring  under  peculiar 
circumstances,  that  is,  connected  with  inflammation  of  veins,  usually 
the  hemorrhoidal  or  spermatic.  It  was  observed  long  ago,  that  in 
the  operation  of  extirpation  of  a testicle  or  testicles,  and  subsequent 
ligature  of  the  cord  to  prevent  hemorrhage,  among  other  accidents 
it  occasionally  happened  that  a collection  of  matter  was  formed 
within  the  substance  of  the  pancreas  or  around  the  gland,  and  the 
same  result  was  observed  to  take  place  in  the  course  of  various  dis- 
eases of  the  testicle  or  its  vessels.  Antony  Petit,  especially,  who 
had  witnessed  several  examples  of  the  suppurative  destruction  of 
the  pancreas,  adduces  them  as  arguments  against  the  propriety  of 
practising  the  operation  of  ligature  of  the  cord  after  castration. 
Portal  also  informs  us  that  he  found  in  a man  dead  after  extirpa- 
tion of  a testicle  and  ligature  of  the  spermatic  cord,  a large  quan- 
tity of  purulent  matter  witliin  the  cord  and  round  the  pancreas. 

The  explanation  of  this  singular  occurrence  is  to  be  found  in  the 
fact,  that  in  the  old  method  of  inclosing  the  cord  within  a ligature, 
the  veins  were  included,  and  very  often  became  inflamed  and  un- 
derwent the  suppurative  inflammation.  When  this  took  place,  the 
matter  formed  in  the  interior  of  the  spermatic  veins  was  transported 
to  various  internal  organs,  sometimes  to  the  kidneys  or  their  ves- 
sels, sometimes  to  the  lungs,  and  sometimes  to  the  pancreas,  and 
there  deposited.  According  to  this  view,  it  is  scarcely  requisite  to 
regard  inflammation  as  the  necessary  preliminary  of  this  suppura- 
tive deposit,  and  probably  the  purulent  matter  found  around  or 
within  the  pancreas  is  to  be  considered  as  transported  from  the  in- 
flamed part  of  the  tied  vein  to  the  other  parts  of  the  venous  system, 
and  among  others  to  the  pancreas. 

Suppuration  of  the  pancreas  has  been  observed  in  persons  dead 
of  ague,  continued  fever,  fever  after  the  suppression  of  some  ha- 
bitual evacuation,  diarrhoea,  hemorrhoids,  the  catamenia,  dropsy, 
marasmus,  convulsions,  epilepsy,  and  hysterid.  Regarding  the 
four  latter  conditions,  it  is  proper  to  observe,  that  the  state  called 
marasmus  is  undoubtedly  the  tabid  condition  with  hectic  already 
noticed,  as  consequent  on  the  purulent  collection  within  the  pan- 
creas ; and  convulsive  symptoms  are  so  often  observed  to  ensue  on 
any  of  the  disorganized  states  of  the  thoracic  or  abdominal  viscera. 


INDURATION  OF  THE  PANCREAS. 


837 


that  they  are  doubtless  to  be  regarded  as  symptoms  rather  than 
preliminary  conditions. 

§ 4.  Scleroma  or  Indurating  Inflammation  of  the  Pan- 
creas ; SciRRHUS  OF  RhAN  AND  MANY  OTHER  AUTHORS,  IMPRO- 
PERLY.— The  pancreas  is  subject  to  slow  chronic  inflammation,  which, 
without  tending  to  suppuration,  renders  the  gland  much  harder  than 
natural,  without,  it  is  said,  otherwise  changing  its  structure.  All 
that  is  meant  by  this,  I presume,  is,  that  the  structure  is  not  sen- 
sibly changed ; for  if  minutely  examined  and  compared  with  the 
sound  pancreas,  it  will  be  found  to  be  considerably  altered.  This 
chronic  inflammation,  though  mistaken  for  scirrhus,  and  as  such 
described  by  Tissot,  Storck,  Morgagni,  Haller,  Baader,  Rahn, 
Portal,  and  others,  is  quite  distinct  from  it,  in  so  far  as  it  does  not 
present  the  true  scirrho-carcinomatous  transformation.  It  appears 
to  be  the  same  change  which  has  been  described  by  Pemberton 
under  the  vague  name  of  Disease  of  the  Pancreas. 

Instances  of  preternatural  hardness  of  the  pancreas  have  been 
noticed  by  Riolan,  Charles  Le  Poix,  De  Paw,  Harder,  Cheselden, 
Haller,  Morgagni,  Tissot,  Baader,  and  Rahn ; but  all  have  con- 
founded, under  the  general  name  of  scirrhus,  a change  which  was 
evidently  the  eflFect  of  inflammation,  probably  of  a chronic  cha- 
racter, acting  on  the  glandular  tissue.  The  observations  of  these 
authors  appear  to  have  been  totally  overlooked,  at  least  by  Eng- 
lish physicians.  Cheselden  had  early  observed  what  has  often 
since  been  confirmed,  namely,  the  effect  of  the  indurated  pancreas 
in  compressing,  the  common  biliary  duct,  and  thereby  causing  fatal 
jaundice.*  But  from  the  time  of  this  author  downwards,  no  at- 
tempt is  made  to  explain  the  anatomical  characters  of  these  in- 
stances of  scirrhus  or  induration.  Dr  Latham  had  the  merit  of 
directing  the  attention  of  the  profession  in  1806  to  the  symptoms 
of  the  disorder,  as  distinct  from  disease  of  the  liver  and  other  ab- 
dominal organs.!  1816,  Mr  Bedingfield,  in  speaking  of  cases 
of  disease  of  the  pancreas,  stated,  that  in  a certain  class  of  cases, 
all  attended  with  dyspeptic  symptoms,  and  often  with  jaundice,  it 
was  found  on  inspection  that  the  pancreas  was  always  more  or  less 

* The  Anatomy  of  the  Human  Body.  By  Wilham  Cheselden.  Twelfth  Edition.' 
London,  1784.  Book  iii.  chap.  v.  p.  166. 

-j-  Remarks  on  Tumours  which  have  occasionally  been  mistaken  for  Diseases  of  the 
Liver.  By  J.  Latham,  M.  D.,  F.  R.  S.,  &c.  Read  11th  Dec  1806.  Medical  Trans. 
Vol.  iv.  p.  47.  London,  1813. 


838 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


hardened,  and  sometimes  increased  in  size  to  the  extent  of  six  times 
its  natural  hulk.*  Mr  Todd  also  described,  in  1817,  an  instance 
of  induration  and  enlargement,  or  what  must  now  be  called  hy- 
pertrophy of  the  pancreas,  pressing  the  common  gall-duct  ;f  and 
Dr  Percival  and  Dr  Crampton  recorded,  in  1818,  examples  of  the 
disorder  attended  with  unusual  compression  of  the  same  duct  and 
the  symptoms  of  jaundice.| 

From  the  dissection  recorded  by  Dr  Crampton,  it  may  be  in- 
ferred that  inflammation  attacking  the  pancreas  renders  that  gland 
harder,  and  larger  or  more  tumid  than  usual,  and  that,  either  in 
consequence  of  this  tumefaction,  it  compresses  and  obstructs  the 
common  gall-duct,  or  the  inflammatory  action  extending  to  the 
surrounding  parts  produces  a morbid  effusion,  which  gives  rise  to 
the  same  result. 

Since  the  time  of  Dr  Crampton,  many  instances  of  different  de- 
grees of  induration  of  the  pancreas,  sometimes  alone,  more  com- 
monly along  with  affections  of  the  duodenum  or  other  abdominal 
organs,  have  been  recorded  by  Dr  Heineken,  Dr  Bright,  Dr  Wil- 
son, Dr  Holscher,  Dr  Ritter,  Dr  Landsberg,  and  other  observers, 
all  of  which  tend  to  show  that  induration  of  the  pancreas  is  not  a 
very  uncommon  disease ; and  that  this  induration,  though  usually 
denominated  scirrhus,  is  either  the  effect  of  inflammation  or  accom- 
panies that  process. 

From  the  cases  recorded  by  these  authors,  it  results  that,  though 
induration  may  affect  any  part  of  the  pancreas,  or  the  whole  of 
that  gland,  yet  most  usually  it  is  the  head  of  the  organ,  that  is  in- 
durated ; and  at  the  same  time  it  may  be  enlarged. 

The  pancreatic  substance  is  then  hard  and  cuts  firm,  grating  on 
the  knife. 

In  some  cases  it  is  stated  to  be  like  cartilage ; in  others  like  the 
boiled  udder  of  the  cow.  Usually  there  are  adhesions  or  recent 
lymph  connecting  the  pancreas  to  other  adjoining  parts.  The  lo- 
bulated  acinoid  structure  is  not  always  very  manifest.  Ritter 

* Compendium  of  Medical  Practice. 

+ History  of  a Remarkable  Case  of  Enlargement  of  the  Biliary  Ducts.  By  Charles 
H.  Todd,  M.  R.  C.  S.  Dublin  Hospital  Reports  and  Communications,  Vol.  i.  p.  325. 
Dublin,  1817. 

J Two  Cases  of  Inflammation  and  Enlargement  of  the  Pancreas.  By  Edward  Per- 
cival, M.  B.,  M.  R.  I.  A.,  Bath.  Read  1st  June  1818.  Transactions  of  the  Associa- 
tion of  the  Fellows  and  Licentiates  of  King  and  Queen  College  of  Physicians  in  Ireland, 
Vol.  ii.  p.  128.  Dublin,  1818.  Additional  Cases,  by  John  Ciampton,  M.  D.,  &c. 
Ibid.  p.  134. 


INDUEATION  OF  THE  PANCREAS. 


839 


states,  that  in  a case  observed  by  him  it  was  no  longer  cognizable. 
In  other  instances,  however,  I am  satisfied,  from  what  I have  my- 
self seen,  that  these  bodies  are  certainly  not  less  distinct  than  be- 
fore. The  change,  of  which  they  are  the  seat,  is  effusion  of  lymph, 
which  becomes  coagulated.  This  effusion  takes  place  both  into 
their  interior,  and  externally  between  the  acini  and  lobules ; and 
when  the  exudation  becomes  consolidated,  the  whole  is  converted 
into  a hard,  firm  cartilage-like  mass. 

In  some  instances  the  head  or  duodenal  end  of  the  pancreas  is 
thus  indurated  and  enlarged,  and  at  the  same  time  the  left  or  sple- 
nic end  may  be  hardened,  while  the  middle  portion  is  comparatively 
healthy  and  natural  in  structure. 

The  duodenum  is  very  generally  rough,  irregular,  and  compres- 
sed ; its  interior  capacity  is  diminished ; and  its  mucous  membrane 
is  vascular. 

With  this  induration  of  the  pancreas,  not  unfrequently  are  asso- 
ciated more  or  less  disease  in  the  duodenum,  as  chronic  ulceration,* 
thickening,  and  similar  changes  in  the  beginning  of  the  jejunum. 

The  following  instance,  given  by  Cruveilhier,  from  an  infant  born 
at  full  time,  shows  that  the  disease  may  take  place  in  the  foetus. 
The  pancreas  presented  a lardaceous  appearance,  like  the  structm-e 
of  a scirrhous  mamma,  without  distinction  of  glandular  grains.  The 
antero-posterior  diameter  was  as  great  as  the  vertical  diameter. 
The  size  of  the  splenic  or  left  end  was  as  great  as  that  of  the  right 
or  head.  The  pancreas  adhered  to  the  supra-renal  capsule  and  the 
right  kidney. 

I think  it  is  hardly  possible  to  doubt  that  the  whole  of  the  cases 
now  referred  to  are  instances  of  chronic  inflammation  of  the  pan- 
creas. It  is  quite  clear  that  they  cannot  in  all  instances  be  regard- 
ed as  scirrhus ; for  several  of  the  cases  mentioned  are  stated  to  have 
been  instances  of  bad  health,  with  symptoms  of  pancreatic  disease, 
from  which  the  patients  recovered.  Thus  Dr  Percival  gives  one 
case  of  this  kind,  in  which  recovery  took  place  under  the  employ- 
ment of  local  blood-letting,  blistering,  restrained  diet,  and  the  use 
of  aperients.  Dr  Crampton  gives  one  case,  in  which  recovery  was 
effected  under  the  same  measures.  Dr  Landsberg  gives  an  instance 
of  what  he  calls  Tabes  Pancreatis,  in  which,  after  about  rather 
more  than  three  months,  the  patient  got  well  under  the  succes- 
sive use  of  mercury,  and  mercurial  and  iodine  ointment,  and 
the  foot-bath  of  nitro-muriatic  acid.  In  other  two  cases,  to  which 

* Two  of  the  eases  given  by  Dr  Bright. 


840 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


lie  applies  the  name  of  Pancreatitis  chronica,  recovery  took  place  in 
like  manner,  under  the  use  of  foot-baths  of  mineral  acid,  (appa- 
rently the  hydrochloric,)  which  were  followed  after  a short  time  by 
critical  diarrhoea.* 

Another  circumstance,  showing  that  these  must  have  been  in- 
stances of  chronic  congestion  or  inflammation,  is  that  most  of  them 
took  place  in  persons  comparatively  young.  The  patient  of  Dr 
Haygarth  was  middle-aged.  In  one  of  the  fatal  cases  of  Dr 
Crampton,  the  age  was  35.  In  another  favourable  case  it  was  32. 
In  Dr  Landsberg’s  first  case  the  age  was  42,  in  the  second  30,  in 
the  third  22. 

The  effects  of  this  change  of  structure  are  of  two  kinds ; one 
order  in  the  adjoining  organs  ; another  in  the  function  of  digestion 
and  the  general  health. 

Those  in  the  contiguous  organs  are  anatomico-pathological,  and 
have  been  in  some  degree  referred  to  already.  The  most  common 
are  adhesions  with  the  duodenum,  the  right  kidney,  the  jejunum, 
and  in  some  instances  with  the  gall-ducts  and  gall-bladder. 

Next  to  these  come  compression  of  the  gall-ducts,  and  usually 
jaundice. 

The  aorta  may  be  compressed;  but  the  vena  cava  and  vena  jjor- 
tae  are  most  frequently  so.  The  result  is  ascites. 

The  duodenum,  however,  is  the  organ  that  suffers  most  in  all  this 
mischief.  Its  calibre  is  contracted ; the  inner  surface  is  excited  and 
injected  ; and  its  first  curvature  is  so  much  obstructed,  that  a sense 
of  painful  distension,  fiatulence,  and  acid  eructations  are  common 
and  almost  constant  results. 

There  seems  no  doubt  that  this  induration  may  proceed  to  ulce- 
ration ; and  in  this  way  ulceration  usually  takes  place  at  the  head 
of  the  gland,  and  finds  its  way  into  the  duodenum.  Though  in 
strict  pathological  language  this  ulceration  is  not  properly  malig- 
nant, yet  to  all  practical  purposes  it  is  sufficiently  so  to  he  regarded 
incurable.  It  almost  never  heals  when  it  has  once  begun.  It  pro- 
ceeds destroying  the  gland,  very  much  like  chronic  ulceration  of 
the  stomach.  The  havoc  then  found  after  death  has  made  most  of 
the  cases  be  denominated  scirrhus  of  the  pancreas. 

The  effects  on  the  digestive  function  are  very  serious.  It  is 

* Einige  Bemerkungeii  iiber  Krankheiteii  lies  untcni  Magcnnuindes  unci  cler  Baiicli- 
speicheklriise.  Vem  Dr  Landsberg  ijract.  Arzte  zu  Alunsterberg  in  Schlesien.  C. 
Ilufelaud’s  .Journal  dor  Practisdieii  Heilkunde.  Fcrtgesetzte  von  Dr  E.  Osaiin. 
lolO.  Siebonter  Stuck  .Tali,  (xci.  Bud.) 


INFLAMMATION  OF  THE  PANCREAS. 


841 


unfortunate  that  Rahn,  who  has  given  the  fullest  collection  of 
cases  of  induration  of  the  pancreas,  has  not  distinguished  the 
disorder  from  scirrhus,  properly  so  named,  and  has  even  given  as 
instances  of  the  latter,  cases  in  which  tumours,  more  or  less  ex- 
tensive, were  formed  from  the  mesenteric  and  meso-colic  glands, 
and  had  then  implicated  the  pancreas.  It  hence  results,  that  it  is 
impossible  to  attach  to  his  history  of  symptoms  that  importance 
which  a correct  critical  semiographical  account  deserves.  It  is  im- 
portant to  know,  however,  that  he  mentions  the  following  as  pre- 
sent in  most  of  the  cases. 

1.  Pains  between  the  ensiform  cartilage  and  navel,  at  one  time 
occupying  the  middle  region  of  the  belly  and  stretching  to  the 
spine,  and  at  another  the  right  or  left  hypochondriac  region.  2. 
Tumour  in  the  same  region,  easily  palpable  by  the  finger,  hard, 
moveable,  causing  a sense  of  weight  while  the  patient  stands  or 
walks,  most  painful  above  the  lumbar  vertebras,  with  great  precor- 
dial anxiety,  especially  after  taking  food  or  drink.  3.  A sense  of 
burning  in  the  stomach,  not  temporary  but  constant,  with  a painful 
sense  of  soreness  and  heartburn  spreading  into  the  oesophagus,  with 
frequent  eructation  of  a watery,  tasteless,  or  acid  fluid  which  re- 
sembles saliva.  4.  Constipation.  5.  Anorexia,  squeamishness ; 
and,  6.  Eventually  vomiting  occurring  at  uncertain  intervals, 
bringing  up  ingesta  and  ropy  phlegm ; and  at  length,  7.  wasting 
( tabes J and  hectic  fever  with  all  their  attendant  symptoms. 

The  chief  objections  to  this  history  are,  that  the  same  series  of 
symptoms  is  liable  to  take  place  in  various  disorders  of  the  stomach, 
the  duodenum,  and  the  liver  ; that  the  pancreas  is  sometimes  found 
indurated  without  any  of  these  symptoms  having  taken  place  ex- 
cepting the  pain  and  occasional  vomiting ; and  that  the  circum- 
stance of  palpable  tumour  is  often  wanting,  and  when  present  is 
not  pathognomonic. 

The  principal  symptoms,  judging  from  the  cases  recorded  by 
the  best  observers,  are  deep-seated  pain  in  the  region  of  the 
stomach,  more  or  less  sickness,  sometimes  vomiting,  with  ema- 
ciation, general  languor,  fever  especially  in  the  night,  and  in  gene- 
ral a yellow  or  jaundiced  colour  of  the  skin.  The  urine  is  in  ge- 
neral scanty  and  high-coloured ; and  though  the  bowels  are  gene- 
rally confined,  and  dyspeptic  symptoms  are  common,  sometimes 
diarrhoea  takes  place  and  proceeds  to  a considerable  degree,  appa- 
rently with  salutai'y  effect.  Wedekind,  who  observed  this  symptom. 


842 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


absurdly  ascribed  it  to  a milder  degree  of  pancreatic  inflammation, 
or,  as  Gautier  expresses  it,  to  increased  irritability  of  the  pancreas. 
It  may,  however,  be  regarded  as  a law  of  inflammation  of  glandu- 
lar tissue,  that,  in  the  early  stage,  the  secretion  is  diminished  or 
suppressed,  and  that,  if  it  seem  to  be  augmented  in  the  latter  stage, 
this  is  rather  the  effect  and  the  proof  of  the.  subsidence  of  the  in- 
flammation and  its  final  disappearance  than  of  increased  action. 

In  one  case  of  this  disorder,  in  which  I had  an  opportunity  of  in- 
specting the  parts  after  death,  I observed  the  progress  of  the  disease 
for  months.  The  patient,  a female  of  about  48,  continued  ill  for  seven 
or  eight  years,  with  pain  in  the  epigastric  region,  and  more  urgently 
unwell  for  about  two  years,  with  pain  and  tenderness  in  the  same 
part,  frequent  attacks  of  sickness  and  vomiting,  occasional  diarrhoea, 
constant  headach,  a pulse  varying  from  88  to  96,  most  usually  at 
92,  rather  full,  and  hot  dry  skin,  though  pale,  blanched,  and  at 
length  leucophlegmatic  complexion.  The  pain,  which  was  most 
felt  in  the  epigastric,  and  towards  the  right  hypochondriac  region, 
was  so  urgent,  that  the  slightest  and  gentlest  pressure  could  not  be 
borne  ; it  was  constant,  and  underwent  no  remission  ; was  distinctly 
i-eferred  to  the  region  specified  by  the  patient  herself ; and  was 
always  relieved  by  local  bleeding,  and  occasionally  by  general 
blood-letting.  The  effect  of  opiates  was  immediate  but  temporary, 
that  of  counter-irritation  by  blister  or  tartar-emetic  ointment  more 
permanent.  As  the  disease  proceeded,  the  fits  of  vomiting  became 
more  frequent  and  urgent,  and  were  accompanied  with  distressing 
hiccup  ; nothing  was  retained  ; the  patient  wasted,  and  became 
waxy-coloured  and  leucophlegmatic ; and  life  was  maintained  for 
some  time  by  nutritious  enemata  with  opiates.  Though  the  ema- 
ciation was  not  visibly  extreme,  yet  the  pale  waxy  appearance  of 
the  surface  and  transparency  of  the  skin,  showed  the  imperfect  and 
scanty  degree  of  nutrition.  Death  took  place  apparently  by  ex- 
haustion and  inanition. 

It  was  then  found  that  the  pancreas  was  exceedingly  hard,  al- 
most like  a stone,  a little  enlarged,  but  not  positively  altered  in 
structure.  It  resisted  the  knife  like  firm  cheese  or  cartilage.  The 
acini,  which  were  the  parts  mostly  altered,  were  of  a reddish-gray 
colour,  very  close  in  texture,  and  extremely  firm.  It  seemed. ra- 
ther less  vascular  than  usual.  This  body  was  felt  during  life,  and 
it  never  could  be  pressed  or  handled  without  causing  much  pain. 

The  gall-bladder  w'as  greatly  distended, — a circumstance  which 

1 


INDURATION  OF  THE  PANCREAS. 


843 


showed  that  the  pancreatic  induration  had  compressed  the  common 
biliary  duct. 

In  general,  when  wasting  is  far  advanced,  the  gland  may  be  felt 
more  or  less  distinctly  by  slight  pressure  on  the  belly,  which  is  also 
attended  either  with  pain  or  tenderness.  In  earlier  stages  of  the  dis- 
ease the  most  eflFectual  mode  of  ascertaining  the  state  of  the  pancreas 
is  to  make  the  patient  lie  prone  on  the  belly,  getting  him  supported 
so  as  to  allow  the  hand  of  the  physician  to  examine  the  abdomen. 
If  in  this  position  the  patient  be  examined  carefully,  in  general  it 
is  possible  to  recognize  not  only  a painful  region,  but  some  swell- 
ing. 

Induration  of  the  pancreas  is  attended,  after  some  continuance, 
either  with  a leucophlegmatic  appearance  and  anasarca,  or  with 
dropsy  of  the  belly,  which,  though  not  an  invariable  consequence, 
may  supervene ; and  in  every  case  of  ascites^  in  which  the  liver  does 
not  appear  to  be  indurated  or  enlarged,  or  affected  with  cirrhosis, 
or  the  kidneys  are  known  not  to  be  diseased,  it  may  be  apprehend- 
ed that  the  pancreas  is  indurated  and  compressing  some  of  the  veins, 
either  the  vena  cava  or  some  of  its  branches. 

In  some  individuals  induration  of  the  pancreas  appears  to  give 
rise  to  that  anomalous  assemblage  of  symptoms  called  hypochon- 
driasis ; and  probably  in  this  manner  we  are  to  explain  the  fact 
mentioned  by  Baillie,  that  in  one  instance  there  were  pain  in  the 
hips  and  a sense  of  numbness  in  one  thigh  or  leg.  Difficulty  and 
pain  in  stooping  are  also  not  unfrequent  symptoms.  It  must  not 
be  omitted  that  this  disease  is  sometimes  one  of  the  lesions  found 
in  the  bodies  of  the  insane. 

These  statements  are,  it  must  be  admitted,  not  satisfactory  ; and 
their  chief  use  is  to  show  the  extreme  difficulty  of  recognizing  the 
presence  of  this  disease  during  life,  at  a period  sufficiently  early 
to  enable  us  to  form  a correct  and  useful  diagnosis.  This 
difficulty  led  Pemberton  to  conclude,  that  it  is  chiefly  by  nega- 
tive reasoning  that  the  physician  must  infer  the  existence  of  dis- 
ease of  the  pancreas ; that  is,  if  in  a case  in  which  there  is  deep- 
seated  pain  in  the  epigastric  region,  and  more  or  less  sickness  and 
emaciation,  the  patient  does  not  at  the  same  time  present  the  other 
symptoms  denoting  the  presence  of  primary  disease  of  the  stomach, 
of  the  posterior  part  of  the  liver,  of  the  gall-bladder  or  ducts,  or  of 
the  small  intestines,  he  may  infer  the  evidence  of  disease,  that  is 
chronic  inflammation,  of  the  pancreas. 


844 


GENERAL  AND  RATHOLOGICAL  ANATOMY. 


To  one  symptom,  which,  if  constant,  must  he  important.  Dr 
Bright,  in  1832,  directed  attention.  This  consists  in  the  discharge 
of  oily  or  fatty  matters  from  the  howels  in  certain  affections  of  the 
pancreas.  In  three  cases  in  which  the  pancreas  was  considerably 
indurated,  and  had  contracted  6rm  adhesions  with  the  adjoining 
parts,  with  ulceration  in  the  duodenum,  there  were  diseharged  from 
the  howels,  with  the  usual  matters,  a quantity  of  material  like 
melted  grease  or  tallow,  and  whieh  was  ascertained,  hy  chemical 
examination,  to  be  either  adipocire  or  stearine.  Dr  Bright  has 
been  led,  from  various  facts,  to  connect  this  symptom  with  disease, 
probably  malignant,  of  that  part  of  the  pancreas  which  is  near  to 
the  duodenum,  and  ulceration  of  the  duodenum  itself.*  There  is 
no  doubt  that  the  suspension  of  the  pancreatic  secretion  must  exert 
great  influence  on  the  process  of  duodenal  digestion  ; but  it  has 
not  been  proved  by  subsequent  cases  that  this  oily  or  fatty  dis- 
charge never  takes  place  without  disease  of  the  pancreas.!  In 
other  cases  the  pancreas  was  merely  indurated. 

§ 5.  Hypertrophy. — Enlargement  of  the  pancreas  as  an  effect 
either  of  chronic  inflammation  or  of  over-nutrition,  is  often  associated 
with  induration  ; but  may  take  place  with  a natural  state  of  the  con- 
sistence of  the  gland.  When  the  gland  does  become  enlarged  in  this 
manner,  it  is  almost  superfluous  to  say  that  the  lesion  causes  more 
or  less  of  a firm,  solid,  tumid  mass  in  the  epigastric  region.  The 
hulk  which  the  hypertrophied  gland  attains  varies  in  dift’erent  cir- 
cumstances, chiefly  according  to  the  duration  of  the  disorder. 
Riolan  mentions  a case  in  which  it  was  as  large  as  the  liver,  (Rio- 
lani  Anthropographia) ; in  a person  tnentioned  by  Tissot,  its  size 
was  three  times  the  natural  size,  (De  Melaena  et  Morbo  Nigro); 
and  in  a woman  seen  by  Storck,  it  is  said  to  have  been  so  large  as 
to  weigh  thirteen  pounds.  In  the  case  of  a woman  of  forty  years, 
detailed  by  Rahn,  the  gland  measured  nine  inches  long  and  seven 
broad,  and  weighed  a little  above  four  pounds,  and  its  internal 
structure  was  like  lard.  Westenberg  describes  a case  in  which  the 

* Cases  and  Observations  connected  with  Disease  of  the  Pancreas  and  Duodenum. 
By  Richard  Bright,  M.  D.,  &c.  Medico-Chirurgical  Transactions,  Vol.  xviii.  p.  1. 
London,  1833. 

Case  of  Jaundice  with  Discharge  of  Fatty  Matter  from  the  Bowels,  &c.  By  E. 
A.  Lloyd,  Esq.  Ibid.  p.  57. 

On  the  Discharge  of  Fatty  Matters  from  the  Alimentary  Canal  and  Urinary  Pas- 
sages. By  John  Elliotson,  M.  D.,  &c.  Medico-Chirurgical  Transactions,  Vol.  xviii. 
p.  117.  London,  1833. 


SOFTEN^JG  OF  THE  PANCREAS. 


845 


gland  weighed  six  pounds.  The  natural  weight  varies  from  one 
ounce  and  a half  to  six  ounces. 

In  some  instances  the  hypertrophy  is  only  partial,  and  it  then 
affects  chiefly  the  right  side  of  the  pancreas,  which  may  attain  the 
size  of  the  fist,  while  the  left  side  is  natural.  (Rahn,  cases  4th, 
5th,  6th,  11th,  12th.)  A common  result,  then,  is  pressure  upon 
and  obstruction  of  the  common  biliary  duct,  and  consequent  dis- 
tension of  tbe  gall-bladder,  and,  if  the  obstruction  be  complete,  a 
jaundiced  colour  of  the  surface. 

Dr  Holscher  records  an  instance,  in  a man  of  48,  otherwise 
stout  and  healthy,  in  whom  the  enlargement,  by  compressing  the 
duodenum^  caused  contraction  or  stricture  of  that  bowel,  and  fatal 
ileus.  The  duration  of  the  symptoms  of  epigastric  pain  was  eight 
months ; but  the  symptoms  of  ileus  continued  not  longer  than  six 
days.  Dissection  presented  no  marks  of  inflammation.  But  the  pan- 
creas was  void  of  its  normal  granular  condition,  soft,  succulent,  and 
fleshy ; its  sections  presented  neither  tubercular  matter,  nor  any 
formation  like  scirrbus,  or  encepbaloma ; but  it  was  enlarged  to  the 
size  of  a foetal  head  of  four  months ; and  it  had  so  closed  the  duo- 
denum for  the  space  of  three  inches,  that  the  contracted  portion 
did  not  admit  a goose-quilh* 

This  enlargement  appears  to  be  of  the  same  nature  as  that  which 
is  observed  to  affect  other  secreting  glands,  as  the  mamma,  the  tes- 
ticle, and  the  liver.  In  general  the  individual  lobes  and  acini  may 
be  observed  to  be  perceptibly  enlarged ; and  usually  large  and  nu- 
merous blood-vessels  are  observed  entering  tbe  gland.  The  en- 
largement seems  to  depend  on  additional  matter  deposited  in  the 
interstitial  spaces  of  the  acini^  and  perhaps  into  their  substance. 

The  case  mentioned  by  De  Haen,  in  which  he  represents  the 
pancreas  to  have  degenerated  into  numerous  scirrhous  tumours  of 
various  size,  closely  cohering  to  each  other,  may  belong  to  this 
head.  Does  the  change  bear  any  analogy  to  the  early  stage  of 
cirrhosis  of  the  liver  ? 

In  some  cases  the  gland  is  enlarged  and  resembles  lard  or  suet. 
In  such  circumstances  the  change  probably  belongs  to  encepha- 
loma. 

§ 6.  Malakosis.  Softening. — Softening  or  diminution  of  con- 

* IMedizinische,  Chinirgische  und  Ophthalmologische  tVahrnehmungen.  I'on  Dr 
Holscher.  Haimoversche  Annalen  fur  die  ges.  Heilkunde  v.  Band  2.  Heft,  1841. 


846 


GENERAL  AND  PATHOLOGlft^L  ANATOMY. 


sistence  is  observed  under  certain  circumstances  to  take  place  in 
the  pancreas.  If  attended  with  increase  of  size,  this  may  be  regard- 
ed as  the  eflPect  of  inflammation.  In  other  instances,  for  example, 
in  persons  labouring  under  scurvy,  in  cachectic  persons,  and  after 
several  eruptive  disorders,  especially  small-pox  and  scarlet  fever, 
it  seems  doubtful  whether  the  diminished  consistence  can  be  as- 
cribed to  inflammatory  orgasm.  Portal  states  that  he  found  it 
much  softened  without  being  reddened  or  swollen,  in  two  children 
cut  off  by  measles ; and  in  the  body  of  a young  man  between  fif- 
teen and  eighteen  years,  who  died  on  the  tenth  day  of  confluent 
small-pox. 

When  the  pancreas  is  softened,  its  texture  is  loose,  soft,  easily 
lacerable,  of  a yellowish  gray  or  yellowish  green  colour,  and  seems 
permeated  by  dirty  purulent  matter. 

When  the  tissue  is  reduced  to  a soft,  greenish-coloured  foetid 
pulpy  mass,  it  is  believed  to  constitute  gangrene  of  the  pancreas, — 
a very  rare  affection.  A case  is  mentioned  by  Portal.*  I have 
seen  the  pancreas  in  this  state,  of  a pale  brick-red  colour,  the  acini 
still  a little  firm,  but  softened  all  round  their  margins,  and  with 
purulent  matter  oozing  from  the  interstices  of  the  gland.  It  seems 
difficult,  therefore,  to  say,  whether  the  change  described  as  soften- 
ing of  the  pancreas  is  to  be  regarded  as  a species  of  diffuse  suppu- 
ration, or  as  gangrene. 

Dr  Holscher  gives  a case,  in  which  a person  who  had  been  dys- 
peptic from  his  30th  year,  began  in  his  39  th  to  suffer  extremely 
from  violent  constriction  in  the  region  of  the  transverse  arch  of 
the  colon,  and  afterwards  from  squeamishness,  acidity,  and  sore 
aphthae  in  the  mouth  and  tongue,  with  great  emaciation.  In  the 
course  of  twelve  months  more,  after  various  oscillations,  these 
symptoms  terminated  fatally.  There  was  then  found,  one  inch 
and  a-half  beyond  the  pylorus,  in  the  duodenum,  an  ulcer  larger 
than  a shilling,  with  slightly  everted  edges,  surrounded  with  many 
blood-vessels,  and  which  had  proceeded  to  perforation  about  the 
size  of  a pea.  The  pancreas,  void  of  its  usual  granular  structure, 
seemed  partially  fleshy,  bore  some  resemblance  to  the  thymus 
gland  of  a three  months’  infant ; was  softened  and  very  abundant 
in  blood-vessels,  which,  when  divided,  effused  blood  copiously. 

In  this  case  the  pancreas  appears  to  have  been  softened,  and  to 


* Anatomie  Medicale,  Tome  v.  p.  354. 


ATROPHY  ; — CONCRETIONS  OE  THE  PANCREAS. 


847 


have  lost  its  characteristic  lobulo-graiiular  structure,  in  consequence 
of,  or  along  with  increased  vascular  distension.* 

§ 7.  Atrophy  of  the  pancreas  or  diminution  of  its  size,  sometimes 
with,  sometimes  without,  condensation  and  induration  of  its  sub- 
stance, may  be  regarded  as  one  of  the  effects  of  enlargement  and 
hypertrophy  of  some  one  of  the  other  abdominal  viscera,  for  in- 
stance the  stomach,  the  liver,  spleen,  or  the  right  kidney.  The  pan- 
creas is  also  in  general  diminished  in  size,  in  chronic  inflammation 
and  ulceration  of  the  intestines.  It  is  not  so  much  an  effect  of  in- 
flammation, as  of  the  opposite  state  of  diminished  supply  of  blood 
for  nutrition.  By  some,  however,  it  is  regarded  as  a remote  eflPect 
of  inflammation,  which  has  either  been  partially  cured,  or  has  pro- 
ceeded to  suppuration,  and  the  matter  of  which  has  been  discharged. 

This  is  the  most  convenient  place  to  mention,  that  the  arteries  of 
the  pancreas  have  been  found  ossified.  This  takes  place  chiefly 
when  the  abdominal  aorta  and  the  coeliac  and  mesenteric  arteries 
are  aflPected  by  osteo-steatomatous  deposition.  The  most  characte- 
ristic case  is  the  following.  A shipmaster,  aged  59,  and  who  had 
been  37  years  at  sea,  had  always  enjoyed  good  health.  All  at 
once,  however,  he  began  to  suffer  from  headach,  anorexia,  squeam- 
ishness, thirst,  a sense  of  burning  heat,  following  the  course  of  the 
oesophagus,  and  constipation.  Emaciation  speedily  followed  ; and 
at  the  end  of  six  weeks,  death.  Upon  inspection  the  pancreas  was 
found  small,  shrivelled,  dense,  of  a deep  gray  colour.  Its  excretory 
duct  was  obliterated ; and  all  the  arteries,  viz.  the  small  branches 
of  the  splenic,  the  pancreatico-duodenal,  and  those  from  the  supe- 
rior mesenteric  were  ossified.! 

It  is  not  improbable  that  the  morbid  condition  of  the  arteries  was 
in  this  case  the  cause  of  the  atrophy. 

It  will  be  seen  from  the  subsequent  head,  that  the  pancreas  may 
be  shrunk  and  rigid  when  the  ducts  are  filled  with  calcareous  mat- 
ter. It  would  be  wrong  to  consider  these  two  circumstances  in  the 
relation  of  cause  and  effect.  But  we  may  infer  that  there  are  two 
conditions  or  forms  of  atrophy  of  this  gland ; one  in  which  it  is 
shrunk,  shrivelled,  and  indurated,  and  another  in  which  it  is  small, 
yet  softened. 

* Medizinische,  Chirurgische  und  Ophthalmologische  AYahrnehmungen.  Von  Dr 
Holscher.  Hannoversche  Annalen  fiir  die  Gesammte  Heilkunde  v.  Band  ii.  Heft  5 
Falle.  S.  328-369. 

! Lancet,  Vol.  ii.  No.  680.  ■ 1835-36,  10th  September,  p.  82.5. 


/ 


848 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


§ 8.  Concretions. — Concretions  are  said  by  Baillie,  who  had 
known  only  one  example,  to  be  a rare  lesion.  Yet  they  have  been 
observed  in  the  pancreas  or  its  ducts  by  several.  Instances  are  given 
by  Van  der  Wiel,  Panaroli,  Matani,  Ten  Rhyne,  Eller,  Sandifort, 
Portal,  Cowley,  and  lastly  by  Dr  Arthur  Wilson  and  Dr  Adam 
Schupmann.  Dr  Wilson  found  the  pancreatic  ducts  in  a man  of 
41,  universally  filled  with  compact  white  earthy  matter,  which, 
examined  chemically,  was  found  to  contain  almost  pure  carbonate 
of  lime  on  a nucleus  of  animal  matter.  The  pancreas  itself  was 
hard  and  shrunk,  in  short  atrophied.*  Dr  Schupmann  found  in 
the  main  duct  of  the  tail  of  the  pancreas,  in  a man  of  57,  a concre- 
tion one  inch  and  six  lines  long,  weighing  three  drachms  and  one 
scruple.  In  the  lateral  ducts  were  two  smaller  concretions.  These 
consisted  of  carbonate  of  lime,  with  animal  mucus,  and  traces  of 
phosphoric  acid.f 

This  fact  as  to  chemical  constitution  corresponds  with  the  result 
of  other  analyses. 

§ 9.  Heterologous  Growths,  a.  Scirrhus. — Of  these  the 
most  common  in  the  pancreas,  if  we  can  trust  the  statements  of 
authors,  is  indubitably  scirrhus,  or  the  common  fibro-cartilaginous 
cancer.  An  immense  number  of  instances  under  this  denomination 
are  recorded  by  authors.  But  when  we  consider  these  cases,  we 
find  no  details  as  to  the  facts,  on  which  they  were  referred  to  that 
head  ; and  all  that  we  learn  is,  that  either  the  pancreas  is  said  to  be 
affected  with  scirrhus,  on  the  testimony  of  the  observer, — or  it  is 
stated  that  the  gland  is  very  hard. 

It  is  impossible,  therefore,  to  avail  ourselves  of  the  cases  record- 
ed by  old  observers  in  this  matter ; and  it  seems  to  me  doubtful 
whether  we  can  ascend  to  a more  remote  period  than  the  last  twelve 
or  thirteen  years  for  evidence  as  to  the  pancreas  being  affected 
with  scirrhus. 

From  various  cases  recorded  by  Mondiere,  Holscher,  Ritter, 
Battersby,  and  other  authors,  excluding  those  cases  which  are  doubt- 
ful or  referable  to  the  head  of  induration,  I think  the  following 
inferences  may  be  established. 

Scirrhus  does  not  very  frequently  attack  the  pancreas  primarily. 
Much  more  frequently  it  appears  rather  to  extend  from  the  stomach  t 

* An  account  of  a Case  of  Extensive  Disease  of  the  Pancreas.  By  Janies  Arthur  f 
Wilson,  M.  D.,  &c.  Medico-Chirurgical  Transactions,  Vol.  xxv.  p.  42.  Iiondon,  1842. 

-}•  C.  W.  Ilufeland’s  Journal.  1841,  April,  xcii.  Bd. 


HETEROLOGOUS  GROWTHS — SCIRRHUS  OF  THE  PANCREAS,  849 


or  duodenum  to  that  gland,  or  it  involves  that  gland  in  common 
with  other  organs.  Holscher  gives  two  cases,  one  of  which  he  calls 
scirrhus  of  the  pancreas,  the  other  cancerous  degeneration  of  the 
pancreas.  In  the  former  he  describes  the  gland  as  greatly  ex- 
panded and  developed,  and  so  cartilaginous  that  it  could  scarcely 
he  cut  by  the  knife.  It  retained,  nevertheless,  its  granular  struc- 
ture. This  case,  therefore,  is  doubtful.  In  the  second,  he  states 
that  however  much  the  pancreas  may  be  disposed  to  scirrhous  de- 
generation, it  nevertheless  resists  the  operation  of  the  carcinoma- 
tous process  in  the  neighbouring  organs ; and  among  60  cases  of 
cancer  of  the  stomach,  in  two  only  did  the  pancreas  partake  of  the 
morbid  action.  One  of  these  was  in  a man  of  80  years,  in  whose 
body  the  pancreas  was  found  little  enlarged,  but  containing,  dis- 
persed through  its  substance,  knotty  tuberosities,  which,  when  di- 
vided, showed  a fibro-cartilaginous  structure,  with  intermixture  of 
dull  streaks,  and  several  of  which  had  proceeded  to  softening. 
The  softened  portion  was  like  dissolved  cheese,  and  exhaled  a pe- 
culiarly disagreeable  odour.  One  of  these  tubercular  elevations 
was  opened  by  an  ulcerative  process  advancing  from  within,  and 
had  elevated  bloody  edges  covered  with  some  thin  fetid  ichor.  It 
had  not  proceeded  to  the  formation  of  fungi.  The  carcinomatous 
pancreas  had  contracted  adhesions  with  the  neighbouring  organs.* 
This  bears  much  more  the  character  of  a heterologous  growth,  and 
appears  to  have  been  an  instance  of  tubercular  scirrhus. 

In  the  case  of  a married  female  of  40  years  old,  and  who,  after 
suffering  for  months  under  pain  in  the  epigastric  region,  anxiety, 
squeamishness,  and  vomiting,  with  great  emaciation,  died,  inspection 
presented  the  following  state  of  parts  ; — the  stomach  normal  as  far 
as  the  indurated  portion  of  the  pylorus ; but  the  pancreas  indu- 
rated, enlarged  to  twice  its  proper  size  ; its  lobular  structure  obli- 
terated ; the  parenchyma  hard  and  solid,  yellowish-white  in  colour  ; 
the  duct  of  Wirsung  and  the  hepatic  vessels  pervious  ; the  former 
filled  with  a viscid  liquid.  The  pancreas  was  morbidly  adherent 
before  and  behind.f 

Dr  Engel  found  in  the  body  of  a female  who  died  in  her  65th 
year,  after  vomiting  and  intestinal  discharges  of  dark-coloured 
matters  with  emaciation,  besides  an  ulcer  in  the  stomach  and  one 
in  the  duodenum,  immediately  beyond  the  pylorus,  which  was 

* Medizinische,  Chirurgische  und  Ophtlialmologische  Wahrnehmungen.  Hanno- 
versche  Annalen,  v.  Band.  2 Heft.  1841. 

t Scirrhosc  Verhartung  des  Pancreas.  Von  Ritter,  Medizinische  Zeitung.  1.  1840. 

3 H 


850 


GENERAL  AND  rATIlOLOGlCAL  ANATOMY. 


covered  by  the  pancreas,  the  pancreas  as  large  as  a fowl’s  egg, 
with  an  uneven,  solid  fibrous  covering,  pale,  bloodless,  with  an  ir- 
regular  fibrous  structure,  with  many  eminences  larger  than  peas 
at  the  surface,  in  which  was  found  a jelly-like  brain-like  matter. 
The  acini  were  completely  compressed.  Right  in  the  middle  of 
the  largest  eminences  were  roundish  bands,  which  might  be  traced 
to  the  pancreatic  duct.  The  latter,  normal  in  diameter,  was  buried 
deep  in  the  mass,  had  thick,  rigid,  resisting  walls  like  those  of  ar- 
teries ; but  upon  quitting  the  mass  now  mentioned  became  suddenly 
large,  flaccid,  and  with  thin  walls. 

If  these  bodies  were  of  medullary  structure,  as  Dr  Engel  seems 
to  think,  then  this  was  rather  an  example  of  encephaloid  than  scir- 
rhous pancreas.  He  allows  that  the  ulcers  in  the  stomach  and 
duodenum  were  not  cancerous  but  simple. 

The  same  observer  found  in  the  body  of  a female  dead  with 
symptoms  of  intense  jaundice  in  her  76th  yeai’,  the  pancreas  small, 
very  firm  and  solid  ; the  excretory  fluct  more  than  a goose  quill  in 
calibre,  with  many  prominent  valve-like  processes  in  the  interior, 
and  filled  with  a gray  coarse  frothy  fluid;  at  the  head,  however, 
directed  outwards,  of  normal  calibre  and  condition.* 

A case  given  by  Dr  Battersby  is  entitled  to  attention  from  the 
correctness  of  its  details.  In  a widow  lady,  aged  60,  who,  after 
suffering  for  twelve  months  from  pains  regarded  as  rheumatic,  be- 
came much  emaciated,  a tumour  about  the  size  of  an  orange  ap- 
peared in  the  epigastric  region,  and  which  was  the  seat  of  pulsation. 

In  the  course  of  one  or  two  months  the  tumour  subsided  ; but  ema- 
ciation proceeded  ; dropsy  followed ; and  death  took  place. 

The  gastro-hepatic  epiploon,  especially  that  part  in  front  of  the  ^ 
foramen  of  Winslow^,  was  very  dense,  hard,  and  thickened ; and 
the  vessels  and  ducts  were  intimately  cemented  together.  This 
thickening  and  hardening  affected  the  cellular  tissue  surrounding 
the  cardiac  orifice  of  the  stomach,  which  resisted  the  introduction 
of  the  little  finger.  The  stomach  was  universally  connected  with 
the  left  extremity  of  the  pancreas,  which  was  hard  and  enlarged, 
and  had  lost  every  trace  of  its  natural  structure.  Near  the  centre 
of  this  gland  was  a thin  translucent  horny  cyst,  which  was  slightly 
prominent,  about  the  size  of  a walnut,  and  lay  directly  over  the 

* Nachti'iig  zu  den  Krankheiten  des  Pancreas  und  seines  Ausfahrungsganges  ; 
von  Dr  Joseph  Engel.  Medizinische  Jahrbucher  des  K.  K.  Osterreich.  Staates.  xxxiii.’'S 
Band  oder  xxiv.  Band  N.  Folge,  1842. 


HETEROLOGOUS  GROWTHS — SCIRRHUS  OF  THE  PA^^CREAS.  851 


aorta.  Its  base  was  surrounded  by  a hard  cartilaginous  scirrhous 
structure  partly  projecting  into  it.  The  rest  of  the  gland  consist- 
ed of  less  solid  yet  unyielding  heavy  substance,  composed  of  dense 
closely  interwoven  membranous  bands. 

The  pancreatic  duct  was  pervious  for  about  one  inch  only  from 
the  duodenum.  The  ductus  choledockus  and  hepatic  ducts  were 
pervious.* 

The  pancreas  is  liable  to  be  involved  in  the  heterologous  struc- 
tures of  other  parts.  Thus  it  may  be  involved  in  new  heterologous 
structure,  arising  either  in  the  interperitoneal  cellular  tissue,  or  in 
the  mesenteric  glands,  or  in  the  pylorus,  or  in  the  duodenum.  In 
the  7 th  case  given  by  Dr  Bright  the  pancreas  was  involved  for  a great 
portion  of  its  space  in  a new  growth  which  had  atfected  the  liver 
and  the  whole  of  the  abdominal  absorbent  glands.f  And  in  a case 
given  by  Schupmann,  in  which  cancer  affected  the  pylorus  and 
pancreas,  the  head  of  the  latter  gland  was  enlarged  to  three  times 
its  usual  size,  while  the  gland 'itself  consisted  of  separate  masses 
mutually  connected,  longish,  from  the  size  of  a hazelnut  to  that  of 
a walnut,  and  the  interior  structure  of  which  was  hard  and  gristly- 
like.|  No  ulceration  had  yet  taken  place.  But  the  mesenteric 
glands  had  partaken  in  the  disease,  and  were  firmly  united  to  the 
pancreas. 

In  all  cases  of  scirrhus  affecting  the  pancreas,  the  lobulo-granu- 
lar  structure  of  the  gland  is  either  greatly  or  entirely  obliterated. 
The  acini  are  so  much  changed,  that  the  granular  character  can- 
not be  recognized.  In  the  place  of  this  there  is  substituted  more 
or  less  of  the  following  structure.  First,  there  may  be  deposited 
a hard  homogeneous  matter  of  whitish  gray  colour,  and  as  firm  as 
cartilage,  which  is  diffused  in  amorphous  portions  varying  in  size 
through  the  gland.  These  masses  are  traversed  by  bluish-white 
lines  of  firmer  matter,  which  look  like  fibrous  bands.  Secondly, 
there  may  be  deposited  the  same  substance  in  the  form  of  tubercles 
or  nodules,  varying  in  size  from  a small  pea  to  a bean.  Both  of 
these  forms  of  new  deposit  tend  to  softening. 

§ 10.  Encephaloid  Disease. — On  this  point  information  is  not 

* Two  Cases  of  Scirrhus  of  the  Pancreas,  &c.  by  Francis  Battershy,  M.  B.  Dublin 
Journal,  vol.  sxv.  p.  219.  Dublin,  1844. 

t Cases  and  Observations  connected  with  Disease  of  the  Pancreas  and  Duodenum, 
Medico-Chirurg.  Transact.,  vol.  xviii.  p.  36.  London,  1833. 

+ Pfdrtner  und  Pancreas-Krebs,  von  Dr  Ad.  Schupmann,  W.  C.  Hufeland,  Journal 
der  Practischen  Heilkunde  Sechsfes  Stuck.  Juni  1840. 


852 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


more  precise  than  on  that  of  common  scirrlms.  Ihave  already  allud- 
ed to  one  case  which  probably  is  to  be  referred  to  this  head  ; and 
hitherto  almost  all  have  been  considered  as  belonging  to  one  cate- 
gory. The  instances  of  adipification,  or  rather  lardaceous  degene- 
ration, mentioned  by  Lobstein  and  Dupuytren,  appear  to  belong  to 
the  present  head.  Bang  records  in  his  reports  the  case  of  a soldier 
of  40,  in  whom,  for  at  least  half  a year,  much  pain  had  been  felt  in 
the  middle  of  the  abdomen,  followed  by  loss  of  appetite,  constipation, 
and  wasting,  and  for  two  months  considerable  swelling  in  the  loft 
hypochondre.  In  the  course  of  six  weeks  more,  after  great  ema- 
ciation, death  took  place ; when,  besides  much  bloody  serum  con- 
tained in  the  abdomen,  the  liver  was  found  occupied  by  white  stea- 
tomatous  tumours,  (manifestly  encephaloid) ; and  the  pancreas, 
which  was  enlarged  to  the  size  of  the  head  of  a child,  consisted  of 
large  glandular  tumours,  in  various  parts  suppurated  and  emitting 
an  offensive  odour,  with  extravasated  dark  putrid  blood.  This 
Bang  denominates  cancer  of  the ‘pancreas.  It  appears  to  have 
been  either  encephaloma  or  chronic  strumous  suppuration.* 

It  seems  doubtful,  indeed,  if  encephaloid  disease  frequently  ori- 
ginates in  the  pancreas.  It  often  arises  in  the  liver,  and  thence 
spreads  to  the  stomach,  duodenum,  and  pancreas  ; and  it  often  also 
arises  in  the  interperitoneal  cellular  tissue.  In  this  manner  I have 
more  than  once  seen  encephaloid  tumours  developed  in  the  abdo- 
men and  affecting  successively  many  different  organs.  In  cases 
of  this  description  globular  masses  of  whitish  semihard  matter  like 
granular  suet  or  cheese,  varying  in  size  from  a walnut  to  an  orange, 
appear  involving  and  penetrating  the  mesentery,  the  intestines,  the 
pancreas,  the  liver,  and  not  uncommonly  the  ovaries  in  the  female. 
It  must,  nevertheless,  be  observed,  that,  amidst  these  masses  of  new 
(leposite,  it  is  usually  possible  to  find  the  substance  of  several  or- 
gans less  injured  than  might  be  expected.  Amidst  this  new  struc- 
ture, the  pancreas  is  in  general  found,  compressed  and  concealed, 
but  retaining  its  characteristic  granular  structure. 

Of  the  changes  and  combination  of  changes  now  mentioned,  ex- 
amples are  given  in  almost  all  pathological  collections.  Thus,  both 
in  the  museum  of  Mr  Langstaff,  and  in  that  of  St  Bartholomew’s 
Hospital,  when  the  pancreas  presents  medullary  or  encephaloid  tu- 
mours, the  same  are  found  in  the  brain,  in  the  kidneys,  in  the  liver, 
or  in  the  interperitoneal  tissue. 

* Selecta  Diarii  Nosocomii  Regii  Fridericiani  Haviiiensis.  Auctore  F.  Lud.  Bang. 
Hafniae,  1709,  ii.  p.  409. 


TYROMA. — MELANOSIS. 


853 


§ 1 1.  Tyroma. — Does  tubercular  structure  affect  this  gland?  In 
some  instances  it  is  possible  to  recognize  in  it  small  bodies  with  the 
aspect  of  tubercles,  when  the  spleen  and  the  peritonaeum  are  affect- 
ed by  these  growths.  At  the  same  time,  that  the  lesion  is  not  very 
frequent  may  be  inferred  from  this  fact,  that  in  tubercular  disease 
of  the  lungs,  when  the  intestines  are  also  much  affected,  the  pan- 
creas is  most  rarely  affected  by  the  same  or  any  similar  deposit. 
It  is  necessary,  however,  to  distinguish  between  strumous  and  scir- 
rhous tubercles.  The  latter,  that  is,  scirrhus  in  the  tubercular  form, 
are  seen  occasionally  ; the  former  very  seldom, 

§ 12.  Melanosis  seems  to  be  more  frequent  than  tubercle  in  the 
pancreas  ; yet  much  less  so  than  either  scirrhus  or  encephalorna.  A 
good  example  of  the  deposite  is  given  by  Langstaff  in  the  third  vo- 
lume of  the  Medico-Chirurgical  Transactions,  and  the  original  of 
which  is  preserved  in  his  museum,  (now  in  the  College  of  Surgeons.) 
In  this  instance  the  disease  affected  the  brain,  liver,  intestines,  ster- 
num, and  ribs ; and  it  projected  externally  in  the  axilla. 

From  a similar  instance  preserved  in  the  museum  at  St  Bartho- 
lomew’s Hospital,  it  may  be  inferred  that  melanosis  is  often  com- 
bined with  encephalorna,* 

Section  IV, 

MORBID  STATES  OF  THE  LIVER, 

The  morbid  conditions,  to  which  the  liver  is  liable,  may  be  dis- 
tinguished into  two  orders ; first,  those  proper  to  the  liver ; and 
secondly,  those  affecting  the  gall-bladder  and  gall-ducts. 

Tbe  morbid  changes  proper  to  the  liver  may  be  enumerated  in 
the  following  order ; Inflammation  of  different  kinds  and  its  effects, 
such  as  adhesion,  suppuration,  induration,  and  softening;  hyper- 
trophy ; atrophy ; cirrhosis ; fatty  degeneration ; concretions  in  the 
ducts ; entozoa,  or  parasitical  animals ; and  the  heterologous  de- 
posits. 

Among  those  belonging  to  the  gall-bladder  and  gall-ducts  must 
be  placed  inflammation  of  these  parts,  and  their  effects ; contraction 
and  obstruction  of  the  ducts ; biliary  concretions  and  their  effects ; 
and  entozoa  or  parasitical  animals. 

§ 1.  Inflammation — When  inflammation  attacks  the  liver,  it 
may  affect  either  the  peritoneum,  or  the  hepatic  substance,  or  both. 

* A Descriptive  Catalogue  of  the  Anatomical  Museum  of  St  Bartholomew’s  Hospi- 
tal. Published  by  order  of  the  Governors.  Vol.  i.  Pathological  Anatomy.  Lou- 
don, 184().  ovo.  Serie.s  p.  317. 


854 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


In  the  former  case  the  disease  constitutes  hepatic  peritonitis,  a dis- 
order already  noticed  generally  under  the  head  of  the  peritoneum. 
One  or  two  points  only  deserve  particular  attention. 

1 . It  is  usually  supposed  that  hepatic  peritonitis  is  always  an  acute 
disease^  or  rather,  that  acute  inflammation  of  the  liver  always  afiects 
the  peritoneum.  This  is  a mistake.  The  disease  may,  like  other 
inflammations  of  serous  tissue,  assume  either  the  acute  or  the  chro- 
nic form ; and  it  is  not  easy  to  say,  from  what  is  seen  in  the  in- 
spection of  bodies,  which  is  the  most  frequent. 

Hepatic  peritonitis  is  a disease  not  uncommon,  especially  when 
the  substance  of  the  liver  is  either  congested,  indurated,  or  affected 
with  cirrhosis.  In  cases  of  this  kind,  almost  uniformly,  the  whole 
convex  upper  surface  of  the  liver  is  found  adhering  to  the  dia- 
phragm. 

Hepatic  peritonitis  is  liable  to  take  place  in  the  concave  surface 
of  the  gland,  when  the  stomach  is  inflamed  or  affected  by  chronic 
ulcer.  This  ulcer,  it  has  been  shown,  most  commonly  is  seated  in 
the  small  arch  of  the  stomach ; and,  if  it  destroy  the  gastric  tissues 
down  to  the  peritoneum,  peritonitis  then  follows,  with  effusion  of  al- 
bumen, which  may  be  in  various  states  of  consistence,  from  soft  and 
semifluid  up  to  orga.nized  membrane,  according  to  the  duration  of 
the  disease. 

Occasionally  inflammation  attacks  the  peritoneum  covering  the 
concave  surface  of  the  liver,  in  the  site  of  the  capsule  of  Glisson, 
and  is  mostly  confined  to  that  region.  This  is  most  commonly,  nay, 
very  generally,  attended  with  yellowness  of  the  surface.  The  in- 
flammation extends  over  the  hepatic  ducts  and  vessels  in  the  cap- 
sule, and  causes  more  or  less  constriction  of  the  ducts. 

2.  Inflammation  may  attack  the  hepatic  peritoneum  at  the  ante- 
rior-inferior margin  of  the  right  lobe,  either  along  with,  or  in  con- 
sequence of,  inflammation  of  the  peritoneal  coat  of  the  colon,  or 
even  the  pyloric  end  of  the  stomach.  The  former  is  the  most  com- 
mon. A good  specimen  of  this  I had  occasion,  on  the  10th  of  Janu- 
ary 1839,  to  observe,  in  inspecting  the  body  of  a man  destroyed  by 
continued  fever.  A band  of  firm  false  membrane,  about  two  inches 
broad,  and  from  three  to  four  inches  long,  extended  from  the  an- 
terior margin  of  the  liver  and  the  fundus  of  the  gall-bladder  to  the 
transverse  arch  of  the  colon,  about  one  inch  to  the  left  of  its  angle, 
and  connected  that  bowel  firmly  to  the  liver  and  gall-bladder.  In- 
stances even  are  recorded,  in  which,  in  consequence  of  biliary  calculi 

(i 


ACUTE  INFLA3IMATI0N  OF  THE  LIVER. 


855 


ulcerating  a passage  out  of  the  gall-bladder  into  the  intestines,  si- 
milar adhesions  had  been  previously  formed  between  the  peritoneal 
coat  of  that  organ  and  the  peritoneal  covering  of  the  bowels.  Si- 
milar inflammation  and  adhesion  take  place  in  India  in  consequence 
of  disease  of  the  colon  and  caecum. 

3.  Inflammation  of  the  hepatic  peritoneum  of  the  inferior  surface 
of  the  liver  may  arise  either  spontaneously,  or  from  some  cause  of 
irritation  in  that  region,  as  biliary  calculi  sticking  in  the  gall-ducts, 
or  inflammation  of  the  duodenum  or  jejunum,  spreading  to  the  cap- 
sule of  Glisson.  In  all  these  cases  the  same  eflFects  are  produced. 
The  membrane  becomes  Injected,  vascular,  and  rough,  and  after- 
wards efliises  albuminous  exudation,  which  unites  the  contiguous 
organs  by  adhesion. 

In  all  the  cases  now  mentioned,  hepatic  peritonitis  arises  from 
some  morbific  cause  applied  to  or  seated  in  the  membrane.  But  it 
may  be  also  the  result  of  another  cause  seated  in  the  hepatic  sub- 
stance. When  the  substance  of  the  liver  is  inflamed,  whether  it 
proceed  to  suppuration  or  not,  it  is  a very  common  consequence  for 
the  peritoneal  covering  over  the  inflamed  or  suppurating  portion  to 
become  red,  injected,  and  at  length  covered  on  its  free  surface  with# 
albuminous  exudation,  which  more  or  less  quickly  unites  the  mem- 
brane with  the  organs  to  which  it  is  applied.  It  may  hence  be  said 
that  though  hepatic  peritonitis  may  often  take  place  without  inflam- 
mation of  the  hepatic  substance,  the  latter  is  almost  never  inflamed 
without  being  followed  or  accompanied  by  hepatic  peritoneal  in- 
flammation. 

§ 2.  Scar-like  Marks  on  the  surface  of  the  Liver. — 
In  examining  dead  bodies,  it  is  not  uncommon  to  observe  on  the 
surface  of  the  liver  marks  like  the  remains  of  scars  or  cicatrices. 
The  peritoneum  at  these  marks  seems  drawn  or  depressed  into  the 
substance  of  the  liver  at  one  point ; and,  radiating  from  this  point, 
are  lines  gradually  lost  in  the  space  of  about  from  half  an  inch  to 
three-quarters  of  an  inch.  At  these  parts,  the  peritoneum  adheres 
very  firmly ; and  there  is  often  a sort  of  contraction  or  drawing  to- 
gether of  all  the  parts. 

The  cause  of  these  appearances  is  in  all  probability  inflammation 
of  the  hepatic  peritoneum,  taking  place  at  a particular  point,  and 
connected  with  inflammation  either  of  the  liver  or  of  the  sub-serous 
cellular  tissue. 

§ 3.  Cartilage-like  Patches. — The  hepatic  peritoneum  is  often 
found  covered  with  patches  of  cartilage-like  matter.  The  con- 


856 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


vex  surface  is  the  most  usual  seat  of  this  deposition  and  transfor- 
mation ; and  it  is  most  common  in  females.  There  are  evidently 
layers  of  albuminous  effusion,  the  result  of  chronic  inflammation. 

§ 4.  Tubercles. — The  hepatic  peritoneum  is,  like  other  parts  of 
that  membrane,  liable  to  be  affected  with  osseous  degeneration  ; 
and  it  may  be  occupied  with  minute  hard  seraitranslucent  tuber- 
cles, when  the  peritoneum  is  affected  by  these  bodies.  All  these 
conditions  are  liable  to  be  attended  with  inflammation  of  the  mem- 
brane, that  is  redness,  congestion,  roughness,  and  exudation  of 
coagulating  lymph,  but  which  is  slow  in  progress,  and  in  other 
respects  of  a chronic  character. 

It  then  usually  happens  that  the  hepatic  peritoneum  adheres 
more  or  less  extensively  and  firmly  to  the  diaphragmatic,  the  gas- 
tric, or  the  muscular  peritoneum.  This  disorder  is  most  usual  when 
the  abdominal  peritoneum  generally  is  affected  by  tubercles. 

It  has  been  formerly  mentioned  that  in  one  order  of  tubercles 
adhesion  is  most  common  ; and  in  another  ascites. 

§ 1.  Inflammation  of  the  Hepatic  Substance. — Inflamnia- 
4|tion  of  the  substance  of  the  liver  has  been  generally,  since  the  time 
of  Cullen  at  least,  believed  to  be  of  a chronic  nature ; and  doubtless 
the  trifling  or  obscure  symptoms  which  appear  in  cases,  in  which 
dissection  discloses  a considerable  abscess  of  the  organ,  are  highly 
favourable  to  this  opinion.  For,  independent  of  the  avowed  diffi- 
culty of  ascertaining  the  existence  of  what  has  been  termed  chronic 
hepatitis  during  life,  almost  all  authors  abound  with  examples  of 
abscess  of  the  organ  discovered  on  dissection,  yet  in  which  no  de- 
cisive symptom  had  led  to  the  suspicion  of  such  an  event.  The 
truth  of  this  I can  verify  by  personal  testimony.  Various  reasons, 
however,  lead  me  to  doubt  whether  hepatic  inflammation  is  invari- 
ably chronic  ; and  several  facts  prove  that  it  assumes,  under  cer- 
tain circumstances,  a sufficiently  acute  form. 

].  In  the  tropical  regions,  inflammation  of  the  hepatic  substance 
is  often  attended  with  acute  pain,  quick  pulse,  and  all  the  marks 
of  a violent  disease  ; and  unless  remedies  be  seasonably  and  ener- 
getically employed,  suppuration  takes  place  in  a period  sufficiently 
short  to  warrant  the  opinion  of  the  inflammation  being  acute, 
(Clark,  (Med.  Com.  xiv.  p.  322,)  Ballingall,  Marshall).  2.  In  tro- 
pical countries,  also,  there  arc  two  forms  of  hepatic  inflammation, — 
one,  acute,  rapid,  and  with  well-marked  symptoms;  the  other  slow, 
long-continued,  and  with  indistinct  symptoms.  3.  Though,  in 


INFLAMMATION  OF  THE  LIVEE. 


857 


temperate  climates,  this  disease  is  undoubtedly  milder,  slower,  and 
less  violent  than  in  countries  where  the  atmospheric  heat  is  exces- 
sive, yet  instances  are  not  wanting  in  which  the  disease  appears 
with  distinct  symptoms,  runs  a rapid  course,  and  terminates  in  more 
or  less  extensive  suppuration.  It  is  true  that  the  distinction,  ac- 
cording to  duration  or  severity  of  symptoms,  is  liable  to  be  vague 
and  undefined ; but  it  is  the  only  one  which  is  pretty  obvious,  and 
which  may  be  useful  in  diagnosis.  4.  Lastly,  both  in  temperate  and 
hot  climates  one  form  of  inflammation  of  the  liver  consists  in  a 
slow  and  gradual  enlargement  of  the  gland,  which  appears  to  de- 
pend on  chronic  congestion,  if  not  inflammation,  without  tending 
to  suppuration,  but  mere  hardening. 

From  these  facts,  it  may  be  inferred  that  hepatic  inflammation  is 
of  two  kinds,  suppurative  and  unsuppurative ; that  the  former, 
which  is  analogous  with  the  phlegmonous  inflammation  of  Cullen, 
Smyth,  and  others  of  the  same  school,  may  be  acute  or  chronic, 
severe  in  character,  and  rapid  in  progress,  or  moderate  in  action, 
and  slow  in  progress ; that  the  latter  is  always  chronic,  unless, 
when,  under  certain  circumstances,  it  may  suddenly  pass  into  the 
acute  form  ; and  that,  though  all  forms  of  the  disease  may  occur 
in  temperate  countries,  yet  warm  or  tropical  regions  are  the  situa- 
tions most  common  for  the  several  forms  of  hepatic  inflammation. 
I enumerate,  according  to  these  principles,  the  following  varieties. 

A.  Acute  suppurative  ; B.  Chronic  suppurative ; C.  Acute  con- 
gestive or  enlarging  ; D.  Chronic  congestive  or  indurating. 

A.  Of  the  first  the  best  examples  are  afforded  in  the  cases  of  Dr 
John  Clark,  occurring  in  the  East  Indies,  Dr  James  Clark,  oc- 
curring in  Dominica,  those  of  Sir  G.  Ballingall,  Mr  Annesley,  and 
Mr  Geddes,  in  the  East  Indies,  and  those  of  Mr  Marshall  in  the 
Island  of  Ceylon.  Its  most  common  symptoms  are  more  or  less 
pain  in  the  right  hypochondriac  or  epigastric  region,  tenderness  in 
some  part  of  the  side,  difficulty  or  pain  in  lying  on  the  right,  some- 
times on  the  left  side,  sickness,  vomiting,  heat,  thirst,  quick  strong 
full  pulse,  and  constipation,  with  scanty  high-coloured  urine.  The 
pain  is  generally  increased  on  pressure ; but,  in  some  instances, 
there  is  merely  an  undefined  sense  of  soreness  or  of  weight,  or  of 
gnawing  emptiness,  deep  in  the  right  hypochondriac  and  towards 
the  epigastric  region.  These  sensations  are  generally  aggravated 
by  lying  on  the  left  side,  in  some  instances  by  lying  on  the  right 
side;  and  occasionally  no  ease  is  procured  unless  when  the  patient 


858 


GENERAL  AND  PATHOLOGICAL  ANATOJIY. 


is  on  his  back.  It  is  probable  that  this  variety  of  complaint  de- 
pends on  the  part  of  the  organ  most  severely  affected.  The  ag- 
gravation caused  by  lying  on  the  left  side  appears  to  denote  that 
the  left  lobe  is  inflamed ; that  resulting  from  lying  on  the  right 
side  denotes  inflammation  of  the  right  lobe,  each  being  respectively 
pressed  by  the  weight  over  a tender  and  inflamed  part;  while  the 
ease  derived  from  the  supine  position  indicates  a deep-seated  inflam- 
mation verging  towards  the  upper  obtuse  margin,  and  the  concave 
surface  of  the  organ.  The  sickness,  vomiting,  and  constipation  are 
not  constant  symptoms  ; but  if  present  with  local  pain  and  quick 
pulse,  denote  the  disease,  with  considerable  certainty,  as  extending  to 
the  concave  surface.  The  heat,  thirst,  quick  strong  pulse,  and  scanty 
high-coloured  urine  are  merely  connected  with  the  general  feverish 
state  of  the  system.  It  rarely  happens  that,  in  this  form  of  hepatic 
inflammation,  there  is  sufficient  enlargement  or  hardening  of  the 
organ  to  cause  a sensible  increase  in  the  bulging  of  the  hypochon- 
driac region.  This  only  occurs  towards  the  latter  end  of  the  dis- 
ease, when  it  threatens  to  terminate  in  suppuration,  or  to  pass  in- 
to the  chronic  form.  Clark  of  Dominica  considers  inability  to 
sneeze  as  a certain  sign  of  the  malady. 

The  acute  hepatic  inflammation  terminates,  Is^,  in  resolution ; 
2d,  in  suppuration ; 3c?,  in  induration  or  chronic  inflammation. 

Termination  by  resolution  is  when  the  symptoms  gradually  de- 
cline either  spontaneously  or  by  the  use  of  suitable  remedies,  and 
the  patient  is  restored  to  health  without  further  complaint.  If  the 
resolution  be  spontaneous,  it  is  generally  accompanied  by  some  eva- 
cuation, for  instance,  hemorrhage  from  the  nose  or  from  the  intestines, 
diarrhoea,  critical  sweating,  or  a copious  sediment  in  the  urine.  Saun- 
ders states  that  he  has  seen  a great  increase  of  bronchial  secretion  at- 
tend the  resolution  of  this  disease  ; and  perhaps  this  is  an  instance 
of  transfer  of  morbid  action.*  Termination  in  suppuration  is  more 
common,  and  is  fatal  either  speedily  or  more  slowly.  In  the  for- 
mer case  the  right  or  left  lobe  is  converted  into  a large  abscess  or 
collection  of  matter,  purulent,  sero-purulent,  or  purulent  with  mas- 
ses of  flaky  lymph.  If  the  whole  hepatic  tissue  be  not  destroyed 
in  this  manner,  the  inner  surface  of  the  abscess  is  somewhat  irre- 
gular, having  the  appearance  of  an  ulcer  thickly  covered  with  pu- 
rulent matter,  or  flaky  lymph.  The  substance  of  the  organ  for 
about  a third  of  an  inch  from  the  ulcerated  surface  appears  unus- 

■*  A Treatise  on  the  Structure,  &c.  p.  208. 


INFLAMMATION  OF  THE  LIVER. 


859 


ually  red,  and  may  be  hardened  a little,  but  beyond  this  the  glan- 
dular substance  is  healthy.  In  some  instances  the  hepatic  sub- 
stance is  destroyed  or  entirely  removed  at  one  spot  or  over  a great 
extent,  and  the  purulent  fluid  is  contained  in  a sac  formed  by  the 
peritoneal  coat.  The  quantity  of  purulent  fluid  varies  from  one  to 
seven  pounds,  the  most  usual  quantity  being  about  two  or  three 
pounds.  At  the  same  the  contiguous  hepatic  substance  is  denser, 
larger,  and  heavier,  and  weighs,  exclusive  of  the  purulent  matter, 
from  one  to  three  pounds  more  than  in  the  healthy  state  it  would 
do.  This  increase  in  bulk  and  weight  is  occasioned  partly  by 
blood  in  its  capillary  system,  partly  by  new  products  from  the 
blood,  causing  swelling  or  enlargement  of  the  organ. 

When  a considerable  abscess  of  one  or  both  lobes  bas  formed, 
death  generally  takes  place  very  quickly,  apparently  in  conse- 
quence of  the  feebleness  and  waste  of  vital  power  induced  by  a 
violent  disease.  If,  however,  life  is  protracted  a little,  the  pur- 
ulent collection  increases  in  size,  and  flnds  its  way  to  the  surface 
of  the  organ.  Ulceration  of  the  peritoneal  covering  takes  place 
at  one  or  more  points,  and  the  contents  escape  by  the  openings. 
An  abscess  may  in  this  manner  be  discharged ; Is?,  into  the  abdo- 
minal cavity ; 2d,  through  the  diaphragm  into  the  air-cells  and 
bronchi ; 3d,  by  the  adhesive  process  into  some  part  of  the  intestinal 
canal,  the  stomach,  transverse  arch  of  the  colon,  or  even  the  duo- 
denum ; 4ith,  by  the  same  process  to  the  outer  surface  of  the  body. 

1.  When  the  matter  escapes  into  the  abdominal  cavity,  it  pro- 
duces immediate  peritoneal  inflammation,  generally  terminating 
fatally.  This  termination  is  most  usual  when  the  abscess  is  seated 
about  the  posterior  inferior  surface,  and  the  acute  margin  of  the 
gland.  This  is  believed  to  be  a rare  termination.* 

2.  If  the  collection  be  seated  about  the  upper  surface  and  right 
lobe  of  the  organ,  the  liver,  diaphragm,  and  lungs  become  united 
by  adhesive  inflammation,  and  the  matter  passes  into  the  air-cells, 
from  which  it  is  discharged  by  expectoration  with  frequent  cough- 
ing. In  fatal  cases  the  hepatic  portion  of  such  an  abscess  presents 
a wide  hollow,  to  the  margin  of  which  the  lungs  and  diaphragm 
are  firmly  attached  ; the  muscular  structure  of  the  latter  is  destroy- 
ed to  the  extent  of  the  ulcerated  surface,  and  the  lungs  are  harden- 
ed, and  void  of  crepitation.  This  termination  is  generally  fatal  in 
a short  time.  The  symptoms  becotne  complicated  with  those  of 

* Vide  Bang  Selecta  Diarii  Havnieusis,  Tom.  ii.  p.  65,  where  a case  with  dissection 
is  given.  A case  by  Mr  Macmillan  Jameson  in  Mem.  Med.  Society,  vol.  iii.  p.  579. 


860  GENERAL  AND  PATHOLOGICAL  ANATOMY. 

pulmonary  consumption,  and  the  patient  is  worn  out  by  incessant 
irritation,  difficult  breathing,  coughing,  and  hectic  emaciation.* 
Yet,  according  to  Marshall,  recoveries  from  this  state  have  occur- 
red ; they  are  indeed  rare,  and  perhaps  occur  only  when  the  ab- 
scess is  small,  and  the  consequent  inflammation  of  the  lungs  not 
extensive.  (Vide  John  Clark,  pp.  405,  407.) 

3.  Mr  Marshall  mentions  a case  in  which  the  left  lobe  adhered 
to  the  stomach,  and  part  of  the  contents  of  an  abscess  had  passed 
through  a large  opening  into  its  cavity.  Sir  G.  Ballingall  states, 
that,  in  many  instances,  extensive  adhesion  takes  place  between  the 
liver  and  transverse  arch  of  the  colon  ; and  though  he  never  met 
with  a case  in  which  an  opening  was  effected,  yet  he  infers  that  it  has 
taken  place,  so  as  to  discharge  matter  and  effect  a cure.  Mr 
Marshall  adheres  to  the  mere  fact  of  no  communication  ever  being 
formed,  and  is  not  aware  of  a cure  having  been  accomplished. 
Dr  John  Clark,  however,  records  a case,  which  he  considers,  from 
the  discharge  of  purulent  matter,  to  have  been  of  this  nature,  (p. 
416).  Two  examples  of  this  communication  are  given  by  M.  Petit.f 

4.  Among  the  cases  of  hepatic  abscess  related  by  Valsalva,  in 
one  the  biliary  duct  communicated  with  the  abscess  by  a large  ori- 
fice, and  was  considerably  dilated.  Morgagni  infers,  that  there  is 
no  reason  to  doubt  that  this  duct  frequently  conveys  blood  and 
purulent  matter  from  the  substance  of  the  liver  into  the  duodenum  ; 
and  he  mentions  that,  in  one  case  in  which  many  pounds  of  purulent 
fluid  were  voided  at  different  periods  during  life,  much  matter  was 
found  after  death  in  the  intestines,  biliary  ducts,  and  liver,  and  the 
ducts  were  much  dilated,  the  intestinal  extremity  being  large 
enough  to  admit  the  little  finger,  (xxxvi.  10.)  The  probability  of 
this  mode  of  outlet  in  consequence  of  purulent  matter  being  form- 
ed either  in  the  vicinity  of  the  ducts,  or  in  the  concave  part  of  the 
liver,  is  noticed  by  Petit,  and  afterwards  by  Saunders ; but  he  ap- 
pears to  have  been  misled  by  speculative  views,  and  to  have  inferred 
that,  because  adhesion  generally  attends  suppuration  and  ulceration, 
it  was  difficult  to  explain  the  mode  in  which  the  hepatic  abscess 
made  its  way  into  the  duodenum,  and  falls  into  some  philosophical 
inconsistencies.  (See  Chap.  iv.  Sect.  i.  7-13.) 

5.  The  passage  of  an  hepatic  abscess  to  the  surface  of  the  body 

* See  cases  by  E.  Barry,  Ed.  Med.  Essays  ; Ur  Ludlow,  Mem.  Med.  Society,  vol. 
iii.  p.  145  ; and  Larrey,  Exj)edition  en  Egypte,  p.  191. 

T Des  Apostemes  du  Foie,  Memoires  de  I’Academie  de  Chirurgie,  tome  ii.  p.  Cl, 
cases  2 and  8.  Paris,  1753. 


INFLAMH^VTIOJ^  OF  THE  LIYER,  861 

appears  to  be  uncomntion ; and  its  spontaneous  opening  by  ulcera- 
tion of  the  integuments  almost  unknown.  Clark  of  Dominica  re- 
cords several  cases  in  which,  by  an  external  incision,  he  discharged 
considerable  quantities  of  matter,  (I,  2,  3,  quarts,  half  a gallon,  a 
pint,  &c.)  sometimes  so  as  to  effect  a permanent  cure.  Marshall, 
however,  states  that  no  case  occurred  in  the  Kandyan  country 
among  any  of  the  classes  of  troops  in  which  it  was  deemed  advis- 
able to  make  an  incision  through  the  abdominal  parietes  into  an 
hepatic  abscess ; and  in  those  cases  in  which  bulging  of  the  false 
ribs  appeared  to  indicate  the  performance  of  this  measure,  it  was 
found  on  dissection  that  adhesion  was  not  sufficiently  intimate  to 
render  it  successful.  In  three  cases  in  which  the  abscesses  were 
small,  the  operation  was  performed  with  good  result. 

The  termination  of  acute  hepatic  inflammation  in  hardening  or 
chronic  disease  shall  be  noticed  afterwards. 

Acute  suppurative  inflammation  of  the  liver  may  be  said  to  be 
endemial  in  tropical  climates.  It  is  so  in  the  West  Indies;  in 
India,  but  particularly  the  Coromandel  Coast,  (John  Clark) ; in 
the  Mysore,  especially  at  Bengalore,  (Mouat) ; and  in  the  whole 
of  the  Presidency  of  Madras  ; in  Ceylon,  (Marshall)  ; and  on  the 
coast  of  Africa,  (Winterbottom).  It  may  occur,  however,  in  tem- 
perate or  cold  climates.  Morgagni  mentions  examples  in  Italy, 
Portal  in  France,  and  Bang  in  Denmark.  (See  Selecta  Diarii,  pp. 
62,  224,  285,  315).  Two  cases  have  fallen  under  my  observation 
in  this  country. 

It  attacks  indiscriminately  natives  and  Europeans,  but  especially 
the  latter,  in  the  East  Indies.  In  Dominica,  the’  negi’oes  were  as 
frequently  attacked  as  the  whites.  Not  unfrequently  it  succeeds 
ague  or  remittent  fever,  or  may  be  complicated  with  them.  Ex- 
posure to  cold,  moisture,  or  extreme  heat  appears  equally  to  favour 
its  production. 

B.  Chronic  suppurative  hepatic  inflammation  differs  from  the 
acute  in  its  mode  of  attack,  the  degree  of  severity,  and  its  effects 
on  the  substance  of  the  organ.  It  generally  comes  on  slowly  and 
insidiously,  either  originally  in  constitutions  previously  exhausted 
by  long  residence  in  hot  climates,  and  repeated  attacks  of  acute 
disease,  or  it  follows  remittent  fever  or  ague.  The  patient  is  lan- 
guid, listless,  averse  to  exertion  either  bodily  or  mental,  and  some- 
times apprehensive.  Yet  he  does  not  complain  of  pain,  or  that 
distressing  uneasiness  which  attends  the  acute  disease.  The  hypo- 
chondriac region,  on  the  contrary,  may  be  insensible,  or  the  seat 


862 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


of  a gnawing  sense  of  emptiness.  At  the  commencement  it  is  not 
enlarged  or  prominent,  but  becomes  so  as  the  disease  advances. 
The  pulse,  at  first  slow  and  natural,  becomes  afterwards  quicker, 
varying  from  90  to  100,  and  sharpish ; the  skin  is  cold,  and  dry  or 
unctuous ; the  tongue  furred  ; the  complexion  sallow,  and  the  look 
anxious.  The  appetite  is  variable,  at  one  time  apparently  good, 
at  others  completely  gone,  while  squeamishness  and  even  vomiting 
may  succeed.  The  matters  discharged  are  chiefly  tough  phlegm, 
with  disordered  bile  and  the  portions  of  food  eaten.  At  the  same 
time,  the  patient  is  hot,  thirsty,  and  restless.  The  bowels  are  ge- 
nerally bound ; the  stools  darker  or  lighter  than  natural ; after- 
wards they  are  loose,  frequent,  and  lienteric.  The  urine  is  scanty, 
depositing  a copious  red  flaky  sediment. 

But  the  most  distinguishing  character  of  this  disease  is,  that 
whatever  variation  these  symptoms  may  present,  and  however  ob- 
scure they  may  be,  there  is  a distinct  accession  of  fever  during  the 
night.  The  pulse  may  be  calm  and  of  natural  frequency,  the  skin 
may  be  cool,  and  the  sensations  of  thirst  and  hunger  may  be  na- 
tural during  the  day ; — in  the  course  of  the  night  the  skin  becomes 
hot,  the  face  reddish,  the  pulse  strong  and  frequent,  the  mouth  dry 
and  parched,  and  the  patient  is  restless,  or  enjoys  only  disturbed 
slumber ; as  morning  advances  slight  sweating  comes  on,  with 
abatement  of  his  sufferings  and  tolerable  sleep.  If  the  disease  is 
not  arrested,  all  the  symptoms,  and  especially  those  of  night  fever, 
become  more  severe  and  distressing ; the  patient  tosses  about  in 
bed  with  a dry  burning  skin,  and  scalding  palms,  constant  and  in- 
satiable thirst,  and,  in  some  instances,  a severe  husky  cough ; his 
nights  become  sleepless,  and  it  is  only  in  the  morning,  after  the 
urgent  complaints  are  relieved  by  partial  sweating,  that  he  falls  in- 
to a laboured,  interrupted,  and  unrefreshing  slumber.  His  strength 
and  flesh  waste,  his  appetite  decays,  and  he  at  length  sinks  into  hec- 
tic, which  shortly  terminates  in  death. 

Dissection  shows,  instead  of  an  abscess  of  considerable  size,  se- 
veral small  distinct  collections  of  purulent  matter  similar  to  the 
small  abscesses  {iwmicae)  of  the  lungs.  They  may  be  very  nume- 
rous, and  not  larger  than  peas,  or  fewer  in  number,  and  as  large 
as  a hen’s  egg.  The  whole  mass  of  the  liver  is  altered  in  colour; 
it  appears  as  if  parboiled,  and  its  texture  is  firmer  than  natural, 
giving  when  cut  the  sensation  of  the  knife  passing  through  a soft 
cartilaginous  mass.  Very  little  blood  issues  from  the  incision.  In 
some  instances  the  surfltce  of  the  organ  is  sprinkled  with  white  spots 


IXFLA3IMIHI0N  OF  THE  LIVER. 


863 


of  various  dimensions,  or  tubercles  are  interspersed  through  its  sub- 
stance. These  appearances  may  be  conjoined  with  hydatids ; but 
these  are  rarely  met  in  the  disease  as  it  occurs  in  India.  The  bile 
differs  from  healthy  bile  in  a slight  change  of  colour  or  consistence ; 
but  it  has  not  been  chemically  examined.  The  gall-bladder  seldom 
presents  any  change  of  structure,  or  is  merely  thickened  in  its  coats. 

This  form  of  hepatic  inflammation  is  very  common  in  India,  es- 
pecially in  those  who  have  resided  long  in  the  country,  who  have 
been  exposed  to  the  causes  of  ague  and  fever,  or  whose  habits  have 
been  rather  intemperate.  It  is  not  unknown,  however,  in  European 
countries ; for  Bang  describes  an  instance  of  it  in  his  Copenhagen 
Reports,  occurring  in  the  month  of  April  1783,  and  with  symptoms 
somewhat  acute.  (Tome  i.  p.  88,  Selecta  Diarii  Havniensis.)  Two 
instances  have  come  under  my  own  notice  in  this  country. 

In  various  instances  of  the  disease,  a single  large  abscess  is  form- 
ed in  the  liver  without  acute  symptoms,  or  with  the  usual  train  of 
chronic  complaints.  I had  occasion  in  1827  to  examine  the  body 
of  an  aged  person  who  had  been  labouring  for  about  five  or  six 
weeks  under  symptoms  of  inflammation  of  the  intestinal  mucous 
membrane,  and  in  whom,  besides  the  usual  traces  of  disease  in  the 
colon,  I found  a large  abscess  in  the  right  lobe  of  the  liver,  con- 
taining fully  four  pounds  of  purulent  matter,  mixed  with  lymphy 
flakes.  To  this  head  Mr  Andree’s  case  in  the  Transactions  of  the 
Medical  Society  appears  to  belong.  “The  formation,”  says  Mr 
Marshall,  “ of  a large  abscess  in  the  liver  sometimes  takes  place 
without  much  indication  of  disease,  in  as  far  as  the  feelings  of  the 
patient  are  concerned.  So  little  obvious  occasionally  are  the  symp- 
toms which  indicate  a large  accumulation  of  pus  in  that  organ,  that 
the  pointing  of  the  abscess  outwards  has  been  mistaken  for  a super- 
ficial collection,  and  an  opening  made  into  it  by  means  of  a lancet. 
The  issue  of  three  or  four  pounds  of  purulent  matter  undeceived 
the  operator.  (P.  155.)  Are  such  collections  to  be  regarded  as 
the  result  of  chronic  inflammation,  or  of  a scrofulous  disease  of  the 
liver,  as  they  are  in  other  organs?  or  are  they  the  result  of  secondary 
deposition  through  the  medium  of  the  veins,  as  takes  place  in  cer- 
tain cases  of  intestinal  ulceration  ? A peculiar  modification  of  he- 
patic suppuration  is  described  by  Sandifort  in  the  eighth  chapter 
of  the  second  book  of  his  Academical  Researches. 

C.  I have  made  a distinct  head  of  acute  congestive  infiammation, 
for  the  purpose  of  referring  to  it  an  affection  of  the  liver,  which  is 
described  by  Dr  Chisholm,  as  prevailing  epidemically  in  some  parts 


864 


GENERAL  AND  PATHOLOGieAL  ANATOMY. 


of  the  West  Indies.  The  disease  began  with  headach,  pain  at  the 
pit  of  the  stomach,  general  languor,  and  a sense  of  tightness  and 
oppression  at  the  breast,  with  difficult  breathing.  The  skin  was 
dry,  harsh,  and  cool ; the  tongue  moist  and  foul,  without  thirst ; 
the  helly  natural ; the  urine  freely  secreted ; and  the  pulse  was 
soft,  about  70  or  80  in  the  minute,  and  of  natural  fulness.  In 
some  cases  the  pulse  was  quick  and  hard  from  the  first,  the  skin 
hot  and  dry,  and  some  swelling  of  the  belly,  especially  at  the  um- 
bilical region,  was  remarked.  The  pain  varied  in  situation,  being 
some  time  confined  to  the  right  hypochondriac  and  epigastric  re- 
gions, in  other  instances  extending  from  these  to  the  shoulder,  es- 
pecially the  right,  across  the  belly  to  the  navel,  or  from  the  navel 
through  to  the  spine.  It  was  remarkable,  that,  when  the  pain  was 
fixed,  it  was  felt  in  the  left  side,  under  the  false  ribs. 

In  about  two  days  the  headach  increased  much,  but  without 
giddiness ; the  pain  at  the  pit  of  the  stomach  became  more  excru- 
ciating; and  shivering  came  on,  with  chilness  of  the  skin  to  the 
touch,  but  an  intense  burning  sensation  when  pressed  strongly. 
The  tongue  was  covered  with  a thick  moist  fur,  purplish  at  the 
edges ; the  cheeks,  nose,  and  eyebrow’s  assumed  a copper  hue,  ex- 
uding large  drops  of  sweat,  while  the  skin,  in  general,  was  cover- 
ed with  an  unctuous  moisture ; the  pulse  rose  from  80  to  120  or 
140 ; dry  cough,  or  rather  a sudden  catching  mode  of  expiration, 
with  a sense  of  compression  of  the  lungs,  came  on  ; and  about  the 
sixth  day,  all  the  symptoms  increasing,  the  skin  became  cold  and 
clammy,  the  pulse  exceedingly  quick  and  small,  deglutition  became 
difficult,  and  coma  came  on,  terminating  in  death. 

On  dissection  the  liver  was  found  greatly  enlarged ; its  surface, 
especially  the  convex,  was  clouded  irregularly  with  red,  purple, 
and  tallow-coloured  spots ; the  peritonaeum  sound  and  transparent. 
The  hepatic  substance  was  of  natural  consistence,  without  any  ap- 
pearance of  suppuration,  but  so  much  enlarged  as  to  occupy  in 
eight  of  ten  cases  not  only  the  right  hypochondriac  and  epigastric 
region,  but  the  left  hypochondre.  Its  vessels  were  enlarged,  butj 
empty.  These  appearances  seem  to  arise  from  an  unusual  accu-? 
mulation  or  congestion  of  blood  in  the  liver.  It  appears  to  be  the^ 
same  described  by  Marshall  at  p.  146,  and  which  he  regards  as  a 
passive  engorgement  of  the  vascular  system  of  the  gland. 

This  sort  of  hepatic  inflammation  prevails  occasionally  as  an  epi- 
demic in  Grenada,  Dominica,  and  others  of  the  later  settled  islands. 
Although  persons  of  all  colours,  ages,  and  of  both  sexes  may  be 


SKLEROMA  OF  THE  LIVER. 


865 


attacked,  yet  blacks  and  young  people  from  eight  to  twenty-five 
years  are  most  liable. 

D.  Skleroma. — To  the  fourth  head,  or  that  of  chronic  conges- 
tive inflammation,  may  be  referred  those  examples  of  liver  disease, 
in  which  the  organ  becomes  slowly  indurated,  generally  with,  some- 
times without,  enlargement,  but  always  with  obscure  symptoms  of 
ill  health,  until  the  structure  of  the  organ  is  so  generally  changed, 
that  it  is  no  longer  fit  for  its  functions  of  receiving  the  venous  cir- 
culation, or  performing  the  secretion  of  bile.  The  symptoms  of 
this  disease  are  so  similar  to  those  of  suppurative  inflammation, 
that  it  is  impossible  in  the  present  state  of  knowledge  to  attempt 
a complete  history.  The  principal,  according  to  Pemberton,  are 
a sense  of  weight  and  dull  pain  in  the  right  side,  weary  heaviness 
of  the  right  arm,  and  frequently  pain  at  the  top  of  the  shoulder. 
The  tongue  is  usually  whitish,  the  appetite  impaired,  the  counte- 
nance sallow,  and  the  bowels  slow,  and  stools  clay- coloured.  The 
pulse  is  about  90,  almost  invariably  intermitting,  and  there  is  a 
sensation  of  fluttering  at  the  pit  of  the  stomach, — symptoms  which 
Pemberton  ascribes  to  the  impeded  motion  of  the  arterial  and  ve- 
nous blood  through  the  hardened  gland.  T hese  symptoms,  how- 
ever, it  may  be  remarked,  appear  only  when  the  disease  is  far  ad- 
vanced, when  the  natural  structure  is  much  injured. 

The  organ  is  harder  than  natural,  and  when  cut  gives  a gristly 
sensation.  Its  surface  is  mottled,  irregular,  and  marked  with  de- 
pressions not  unlike  cicatrices.  Its  substance  is  also  generally 
paler  than  natural,  sometimes  of  a wood-brown  colour ; and  some- 
times like  a recent  section  of  nutmeg  in  tint ; and,  if  immersed  in 
clear  water,  appears  quite  different  from  the  sound  state.  It  is 
traversed  with  gray  or  light-coloured  particles,  which  seem  to  be 
infiltrated  between  the  acini,  or  glandular  granules.  In  some  in- 
stances it  is  possible  to  distinguish  between  the  acini  a bluish- gray 
firm  sort  of  substance,  which  is  indurated  cellular  tissue. 

Not  unlike,  perhaps,  is  the  hard  state  of  liver  observed  in 
drunkards.  Dr  Marshall  describes  them  as  yellowish,  containing 
little  blood,  and  communicating  a gristly  sensation,  when  divided, 
sometimes  loose  and  granular,  at  others  solid  and  tenacious,  weigh- 
ing generally  five  pounds. 

Such  a state  of  the  liver  gives  rise  to  all  the  symptoms  of  imper- 
fect digestion  and  impaired  nourishment,  and  eventually  terminates 
in  dropsical  effusion  within  the  peritonceum  (^ascites,')  or  uncon- 

3 I 


866 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


trollable  hemorrhage  from  the  mucous  surface  of  the  intestinal 
canal.  This  is  the  early  stage  of  that  change,  which  is  afterwards 
to  he  described  as  kirrhosis. 

This  disease  may  succeed  the  acute  form,  or  may  be  developed 
slowly  and  insensibly  after  ague,  remittent  fever,  or  in  the  persons 
of  those  accustomed  to  the  use  of  spirituous  liquors.  It  is  certainly 
a common  disease  in  tropical  climates,  but  is  by  no  means  unknown 
in  more  temperate  latitudes.  It  is  much  seldomer  found  in  females 
than  in  males. 

§ 2.  Anatomico-pathological  causes  of  suppuration  and 

ABSCESS  OF  THE  LIVER.  INFLUENCE  OF  SUPPURATIVE  DISEASE 
IN  OTHER  TISSUES.  INFLUENCE  OF  PHLEBITIS. ThoUgh  the 

inquiry  into  the  circumstances  acting  as  precedents  or  antegre- 
dients,  and  esteemed  causes  of  suppuration  of  the  liver,  involves 
the  consideration  of  causes  of  inflammation  in  general,  yet  the 
formation  of  purulent  collections  within  the  substance  of  the  liver, 
is  attended  by  circumstances  so  peculiar,  that,  in  order  to  render 
the  pathological  history  of  these  collections  complete,  it  is  necessary 
to  consider  these  circumstances  a little  in  detail.  Abscess  of  the 
liver,  indeed,  is  a lesion  so  frequent,  and  in  a certain  number  of 
cases  takes  place  so  steadily  and  regularly,  yet  so  insidiously,  and 
often  in  connection  with  injuries  of  the  head,  that  the  subject  is  en- 
titled to  particular  consideration. 

The  circumstances  usually  observed  to  precede  suppurative 
inflammation  of  the  liver  are ; 1st,  external  violence  or  injury ; 
2d,  internal  irritation,  as  from  the  presence  of  bones,  concretions, 
or  other  objects  which  may  irritate  the  gland ; 3d,  suppurative 
inflammation  of  bones,  especially  of  their  veins ; 4th,  inflammation 
of  a vein  or  veins,  whether  purulent  or  lymphy  ; 5th,  the  presence 
of  ulcers  in  the  intestinal  or  colic  mucous  membrane,  or  ulcers  in 
the  stomach,  duodenum,  gall-bladder,  or  gall-ducts,  or  ulcers  or 
abscesses  in  the  pancreas ; 6th,  previous  congestive  states  of  the 
liver  ensuing  on  the  operation  of  excessive  solar  or  atmospherical 
heat ; and  7 th,  the  operation  of  the  poison  or  miasma  producing 
intermittent  and  remittent  fever. 

Of  all  these  causes,  though  it  be  difficult  to  appreciate  the  com- 
parative influence  of  each,  yet  little  doubt  can  be  entertained  that 
the  most  common  and  the  most  potential  are  venous  inflammation, 
or  the  presence  of  purulent  matter  in  certain  veins,  and  ulceration 
of  the  intestines,  either  small  or  great. 

1.  External  violence  is  rarely  the  cause  of  hepatic  abscess. 


PATHOLOGY  OF  METASTATIC  ABSCESS  OF  THE  LIVER.  867 


More  commonly  this  produces  either  laceration,  with  hemorrhage, 
or  it  gives  rise  to  inflammation  of  the  hepatic  peritoneum,  which 
is  then  found  to  have  formed  adhesive  connection  with  the 
diaphragm,  with  the  internal  surface  of  the  hypochondriac  region, 
or  with  the  stomach,  colon,  duodenum,  or  kidney.  Lentin  re- 
cords one  case  from  external  violence.* * * §  Bretin  mentions  another 
which  he  ascribes  to  this  cause.f  And  two  cases  are  recorded  by 
M.  Petit  the  younger,  (Case  3d,  the  kick  of  a horse ; Case  4th,  a 
contusion  on  the  epigastric  region).^  Yet  it  is  evidently  not  frequent. 
Among  sixty  cases,  collected  in  tabular  form  from  different 
sources  by  Dr  Budd,  in  one  only,  a case  recorded  by  Andral, 
could  the  disease  be  traced  to  a blow.  In  this  case  were  two 
abscesses  on  the  convex  surface ; and  in  all  probability  they  were 
collections  of  purulent  matter  between  the  hepatic  and  hypochon- 
driac peritoneum. 

2.  From  the  irritation  of  internal  objects  the  disease  is  more 
common.  Thus  cases  are  recorded  from  the  presence  of  biliary 
concretions.  § In  general,  the  presence  of  these  bodies  causes,  first, 
inflammation  and  ulceration  of  the  gall-bladder  and  gall-ducts, 
and  then  of  the  hepatic  substance.  One  of  the  most  pointed  cases 
is  given  by  Mr  George  Mallet,  of  Bolton-le-Moors.  A clergy- 
man who  had  been  ill  with  general  bad  health,  accompanied  with 
fits  of  excruciating  pain  in  the  epigastric  region,  died  after  the  course 
of  eight  years.  Inspection  disclosed  an  ulcerated  opening  through 
the  coats  of  the  gall-bladder,  communicating  with  an  abscess  beneath 
the  concave  surface  of  the  liver,  containing  about  six  ounces  of  puru- 
lent matter.  The  ulceration  was  caused  by  the  irritation  of  a mo- 
derately-sized gall-stone  which  was  found  near  the  opening,  but  still 
within  the  gall-bladder.  The  pancreas  contained  in  a cyst  a gall- 
stone about  three-quarters  of  one  inch  in  diameter,  and  which  must 
have  ulcerated  its  way  into  that  gland  at  some  period  anterior,  as 
no  recent  traces  of  inflammation  or  suppuration  were  observed.  || 

3 and  4.  Hepatic  abscess  after  venous  inflammation  is  much 
more  frequent.  In  16  cases  which  fell  under  the  observation  of 

* Beobachtungen  Eineger  Kranken,  p.  94. 

-j-  Journal  de  Medecine,  Tom.  Ixv.  p.  546. 

$ Memoires  de  I’Academie  de  Chirurgie.  Tome  ii.  p.  59. 

§ Ephemerides  Naturae  Curios.  Dec.  I.  Ann.  I.  Obs.  66.  Obs.  105. 

Fournier  in  Journal  de  Medecine,  Tome  xlv. 

Lombart  in  Recueil  Periodique  de  la  Societe  de  Medecine  a Paris,  No.  32. 

1|  Transactions  of  the  Provincial  Medical  and  Surgical  Association.  Vol.  ix. 
art.  ix.  London,  1841. 


868 


GENERAL  AND  rATHOLOGICAL  ANATOMY. 


Louis  and  Andral,  four  may  be  traced  to  this  source.  In  15 
cases  seen  by  Dr  Budd  in  the  Dreadnought  hospital  ship,  only  one 
belongs  to  tins  head. 

Inflammation  of  any  vein  may  be  followed  by  the  formation  of 
purulent  matter  in  one  or  more  collections  in  the  liver ; but  the 
veins,  in  which  inflammation  is  most  generally  followed  by  this 
result,  are  the  veins  of  hones,  often  very  minute,  and  the  veins  of 
the  intestinal  viscera,  from  the  stomach  to  the  rectum. 

The  influence  of  inflammation  in  the  veins  of  bones  in  producing 
hepatic  abscess  appears  in  different  modes.  One  of  the  most  com- 
mon is  after  injuries  of  the  skull. 

It  had  been  observed  by  Pare,  Pigray,  (1658,)  De  Marchettis, 
(1665,)  a Meek’ren,  (1682,)  and  other  surgeons  of  the  seventeenth 
century,  that  after  wounds  of  the  head  and  fractures  of  the  skull, 
abscess  of  the  liver  was  an  occurrence  so  common,  as  always  to  be 
apprehended.  Various  attempts,  some  odd  enough,  were  made 
to  explain  this  combination  of  pathological  phenomena,  which 
was  too  regular  to  be  regarded  as  accidental.  Little  regard  was 
given  to  the  modes  of  explanation,  however,  till  the  middle  of  the 
following  century,  when,  within  the  lapse  of  some  years,  the  sub- 
ject exercised  the  ingenuity  of  Petit,  Bertrandi,  Andouille,  Pou- 
teau,  and  other  members  of  the  French  Academy,  and  Richter, 
Bianchi,  Morgagni,  Cheston,  (1766,)  and  other  observers  in  dif- 
ferent countries  of  Europe, 

Previous  to  the  time  of  Bertrandi,  two  opinions  appear  to  have 
been  entertained  regarding  the  cause  of  hepatic  suppuration  after 
injuries  of  the  head.  Pare,  a Meek’ren,  and  the  cotemporaries  of  the  « 
latter  merely  note  the  conjunction  of  the  two  phenomena,  and  "3 
suppose  the  suppuration  first  formed  within  the  brain,  and  thence  ^ 
absorbed  and  deposited  in  the  liver.  By  another  party,  among 
whom  may  be  placed  Goursaud,  it  was  ascribed  to  sympathetic  af-^jB 
fection  of  the  nerves,  or  the  reflux  of  purulent  matter.  This  author,' 
in  a memoir  presented  to  the  Academy  in  1751,  gives  two  cases,  in  3 
one  of  which  hepatic  abscess  followed  a wound  of  the  finger,  and  in  5 
another  a blow  on  the  tihia^  and  ascribes  them  generally  to  nervous  A 
influence.*  ^ 

This  phenomenon  Bertrandi  ascribed  to  derangement  in  the 
motion  of  the  blood  in  the  brain.  He  supposed  that,  after  every 
violent  concussion  of  the  brain,  the  blood  flows  in  greater  abun- 

* Recueil  cles  Pieces  qui  ont  concouru  pour  la  Prix  de  PAcademie  de  Chirurgie, 
Tome  iii.  Paris,  1759.  Sur  la  Metastase,  p.  3. 


PATHOLOGY  OF  METASTATIC  ABSCESS  OP  THE  LIVER.  869 


dance  to  this  organ,  and  returns  in  greater  quantity  by  the  jugidar 
veins ; so  that  while  a large  stream  is  brought  downwards  by  these 
veins,  and  a considerable  quantity  of  blood  is  conveyed  by  the 
superior  vena  cava  against  the  inferior,  the  blood  of  the  latter  is 
made  to  regurgitate  and  accordingly  pass  into  the  vena  cava 
hepatica  and  its  tributaries ; and  in  this  manner,  more  blood  than 
the  liver  is  capable  of  admitting  being  thrown  on  the  vessels  of  that 
organ,  inflammation  follows,  and  terminates  in  suppuration  and 
gangrene,  the  former  most  commonly.* 

This  theory  was  favourably  received  by  the  French  academicians, 
especially  David  ; and  was  illustrated  and  commended  by  M.  An- 
douille.f 

The  justice  of  this  hypothesis  was  questioned  in  this  country  by 
Cheston,  and  in  France  by  Pouteau. 

Cheston  expresses  his  general  belief  of  the  improbability  of  the 
disturbance  in  the  circulation  assumed  by  Bertrandi,  and  has  re- 
course to  three  suppositions  in  order  to  explain  the  occurrence  of 
hepatic  suppurations  after  injuries  of  the  head.  Is?,  Abscesses  may 
exist  in  the  liver  after  an  injury  received  on  the  head,  without  be- 
ing derived  or  occasioned  by  falling,  from  the  head  to  that  abdomi-  ^ 
nal  viscus.  2d,  Abscess  in  the  liver  may  be  the  result  of  transla- 
tions of  matter  from  one  part  to  another,  as  are  frequently  observed 
after  amputation  of  the  larger  limbs.  3d,  In  severe  injuries  of  the 
head,  the  functions  of  the  liver  are  injured  by  sympathetic  irritation 
of  its  vessels  and  neighbouring  parts  from  the  diseased  state  of  the 
brain  ; and  this  disorder  may  cause  obstruction,  terminating  in 
suppuration. 

To  these  Cheston  adds  as  an  accessory  circumstance,  that,  in 
those  accidents  in  which  the  brain  suffers,  as  by  falls  from  some 
height,  being  thrown  violently  from  a horse,  the  body  must  re- 
ceive a severe  shock,  which  may  not  only  aggravate  the  injury 
inflicted  on  the  head,  but,  from  the  size  and  soft  pulpy  texture  of 
the  liver,  affect  the  functions  of  that  viscus  in  particular,  and  thereby 
not  a little  assist  in  confirming  those  obstructions  which  afterwards 
could  not  be  terminated  but  by  suppuration. j; 

* Sur  les  Absces  du  Foie  qui  se  forment  a J’occcision  des  playes  de  la  tete.  Par 
M.  Bertrandi.  Memoires  de  I’Academie  de  Chirurgie,  Tome  iii.  p.  484.  Paris,  1757. 

t Observations  sur  les  Absces  du  Foie,  par  M.  Andouille.  Memoires  de  I’Acade- 
mie de  Chirurgie,  Tome  iii.  p.  506.  Paris,  1757. 

X Pathological  Inquiries  and  Observations  in  Surgery  from  the  Dissection  of  Mor- 
bid Bodies,  Ac.  By  Richard  Biwvne  Cheston.  Gloucester,  1766.  4to,  chapter  iii, 
p.  32—42. 


870 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


The  doctrine  of  Cheston  was  long  afterwards  espoused  in  a di- 
vided form  by  Desault  and  Richerand. 

According  to  Pouteau,  on  the  other  hand,  who  maintained  that 
it  was  not  proved  that  either  the  quantity  or  the  velocity  of  the 
blood  in  the  superior  cava  was  increased,  the  impediment  to  the  cir- 
culation takes  place  in  the  arteries.  Admitting  that  after  a blow  on 
the  head  the  blood  is  accumulated  in  the  arteries  of  the  brain,  this 
accumulation  extends,  he  maintains,  to  the  carotid  and  vertebral  arte- 
I’ies;  and  consequently,  the  blood  being  resisted  in  the  upper  divisions 
of  the  arterial  system,  is  accumulated  in  the  abdominal  aorta  and  the 
rest  of  the  blood-vessels  ; while  the  substance  of  tbe  liver  being  soft, 
and  its  vessels  large  and  numerous,  readily  gives  way  to  this  new 
orgasm,  and  becomes  affected  by  inflammation  and  suppuration.* 
Desault  rejected  both  explanations,  and  confined  bimself  to  ad- 
mitting tbe  fact  of  a relation  unknown,  but  real,  between  the  brain 
and  the  liver,  more  intimate  than  between  other  organs ; and  the 
proof  of  this  relation  shown  by  the  living  body  by  sickness  and  vo- 
miting ; and  in  the  dead  body  by  the  formation  of  abscesses  in  the 
gland.f  This  explanation,  or  rather  statement,  of  the  two  facts 
% was  long  received  in  the  French  schools,  apparently  in  consequence 
of  the  high  reputation  of  its  author,  and  his  commentator  Bichat. 

Curtet,  a military  surgeon  at  Brussels,  appears  first,  in  1800, 
to  have  doubted  the  sufficiency  of  all  those  hypotheses.  Regarding 
these  hepatic  collections  as  secondary  or  consecutive,  he  looked  for 
some  other  cause  than  any  hitherto  assigned ; and  this  cause,  he 
believed,  he  found  in  the  absorbing  function  of  tbe  lymphatic  sys- 
tem. Goursaud,  we  have  seen,  had  shown  that  hepatic  suppu-  ^4 
ration  may  follow  ordinary  suppurating  wounds  of  the  extre-^i 
mities.  Roose,  a surgeon  at  Antwerp,  had  communicated  to  the 
Society  of  Medicine  and  Surgery  at  Brussels,  a memoir  containing  - ■ 
cases  of  whitloe,  in  consequence  of  which  abscesses  were  found  in 
the  liver.  Rejecting  the  explanation  of  this  sym-phenomenon  given 
by  Roose,  but  receiving  the  fact,  which  he  confirms  by  other  two 
cases,  Curtet  ascribes  the  suppuration  in  the  liver  to  absorption  of 
matter  by  the  lymphatics,  and  the  transport  of  the  same  by  these 
vessels  to  the  liver,  first,  into  the  thoracic  duct,  and  thence,  both  by 
the  hepatic  artery  and  portal  vein  to  the  gland.  He  invokes  also 

* Melanges  de  Chimi-gie  par  M.  Claude  Pouteau,  D.  M.  et  C.  A Lyon,  1760.  P. 
123  ; et  Oeuvres  Posthumes  de  M.  Pouteau,  Tome  ii.  Paris,  1783.  P.  111. 

Oeuvres  Chirurgicales,  2 tomes.  Paris,  1801. 


PATHOLOGY  OF  METASTATIC  ABSCESS  OF  THE  LIVER.  871 


the  aid  of  various  accessory  causes ; viz.  the  size  of  the  liver,  the 
softness  and  vascularity  of  its  structure,  and  the  slowness  with 
which  its  blood  moves  through  the  organ.* 

It  is  impossible  to  deny,  that  the  single  fact  of  proving  suppura- 
tion of  the  liver  in  other  circumstances  besides  those  after  injuries 
of  the  head,  was  one  great  step  in  the  inquiry ; and  to  refer  the 
process  to  the  absorbing  powers  of  the  lymphatic  vessels  was  an- 
other. It  showed  at  once  that  hepatic  suppuration  might  take  place 
in  the  course  of  suppurative  processes  in  other  parts  of  the  body. 

It  is  singular,  that,  in  this  respect,  the  memoir  of  Curtet  has  been 
so  much  neglected. 

Dissatisfied  with  the  whole  of  these  accounts  of  the  connection  of 
these  two  phenomena,  Richerand  brought  forward  a difierent  view, 
first,  in  1803,  and  afterwards  in  1815.  According  to  this  author, 
the  large  size  and  the  weight  of  the  liver  are  the  main  cause  of  its 
becoming  the  seat  of  suppuration  in  consequence  of  injuries  of  the 
head.  The  weight  of  this  gland,  between  three  and  four  pounds,  is  so 
considerable,  that  it  exercises  on  the  diaphragm  great  tension,  which 
causes  inconvenience  and  pain  unless  counteracted.  The  liver  also, 
from  its  size,  weight,  and  the  looseness  of  its  tissue,  void  of  fibres  ^ 
or  plates,  is  easily  lacerated  by  slight  violence ; and,  of  all  the  or- 
gans, is  next  to  the  brain  most  exposed  to  the  eflfects  of  concussions 
and  shocks,  as  in  falls  from  some  height. 

In  illustration,  he  gives  two  cases ; and  conversely  one,  in  which, 
after  a blow  on  the  head,  causing  fracture  and  fatal  inflammation 
of  the  brain,  the  liver  was  quite  sound.f 

Not  satisfied  with  this  evidence,  Richerand  tried  experimentally 
the  effect  of  throwing  dead  bodies  from  a height  of  eighteen  feet 
above  the  ground  on  the  pavement  below.  By  precipitating  in  this 
manner  more  than  forty  dead  bodies,  he  found  that  the  brain  and 
the  liver  were  always  more  or  less  injured  ; that  in  some  cases  the 
latter  presented  deep  lacerations ; that  heavy  bodies  presented  the 
most  severe  injuries  ; and  that  while  fractures  of  all  kinds  and  dif- 

* Observations  et  Reflexions  sur  les  Depots  Consecutifs  qui  ont  lieu  au  Foie, 
particulierement  a la  suite  des  Lesions  traumatiques.  Par  le  Cn.  Curtet,  officier 
de  Sante  a I’Hopital  Militaire  de  Bruxelles,  &c.  &c.  Actes  de  la  Societe  de  Medecine, 
Chirurgie,  et  Pharmacie  etablie  a Bruxelles,  Tome  i.  2ieme  partie.  A Bruxelles,  An. 

8.  1 800.  P.  93. 

t Nosographie  et  Therapeutique  Chirurgicales.  Par  M.  Le  Chevalier  Richerand, 

Prof.  d’Operations  de  Chirurgie,  &c.  Cinquieme  edition,  Tome  iiiieme,  p.  70 75. 

Paris,  1821. 


872 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


ferent  luxations  were  observed,  no  viscus,  not  even  the  brain,  suf- 
fered more  than  the  liver  from  these  violent  concussions  produced 
artificially  by  falls. 

It  is  easy  to  see  that  this  explanation  is  the  same,  in  one  circum- 
stance, as  that  given  in  1766  by  Cheston. 

The  explanation  of  Richerand  was  very  generally  received,  both 
in  France  and  in  various  countries  of  Europe. 

That  the  explanation,  nevertheless,  was  unsatisfactory  and  ina- 
dequate, appears  from  the  fact,  that  hepatic  abscesses  are  observed 
in  the  case  of  injuries  of  the  head,  in  which  the  individual  had  sus- 
tained no  fall,  and  his  person  had  received  no  shock,  except  the  blow 
on  the  skull,  and  in  injuries  and  especially  compound  fractures  of 
the  extremities. 

Though  Curtet  had,  at  the  end  of  last  century,  made  a consi- 
derable advance  in  tbe  right  line  of  inquiry  on  this  subject,  it  was 
not  till  near  thirty  years  after,  that  the  explanation,  which  may  be 
regarded  as  the  correct  one,  was  given.  Mr  Arnott  showed,  in  a 
paper  read  to  the  Medico-Chirurgical  Society  in  1828,  that,  when 
the  phenomena  of  injuries  of  the  skull  or  other  external  parts  are 
# followed  by  suppuration  or  abscess  witbin  the  liver,  there  is  every 
reason  to  believe  that  the  veins  of  the  former  part  are  inflamed,  and 
that,  in  consequence  of  this  venous  inflammation,  secondary  deposits 
take  place  in  the  liver.  Mr  Arnott  showed,  in  short,  that  second- 
ary deposits  take  place  in  this  way  both  in  the  abdominal  and  tbe 
thoracic  viscera,  and  sometimes  in  both  sets  of  organs  at  once.  He 
further  showed,  that  the  injury  which  the  head  had  sustained  con- 
sisted, in  two-thirds  of  the  cases,  of  fracture  or  fissure  of  the  skull, 
in  all  compound ; and  though,  in  one-third,  the  skull  was  neither 
fractured  nor  fissured,  yet  with  wound  of  the  soft  parts,  in  several, 
part  of  the  outer  table  and  diploe  had  been  sliced  off,  while  in  all 
the  bone  was  exposed.  As  inflammation  of  the  osseous  substance 
must,  in  all  these  cases,  have  existed,  Mr  Arnott  infers  that  this 
process  taking  place  in  the  numerous  veins  ramifying  between  the 
two  tables  of  the  skull,  and  in  those  distributed  to  the  soft  parts 
externally,  may  be  attended  with  similar  consequences  to  those 
which  follow  phlebitis  in  other  parts;  that  is,  collections  of  matter 
in  internal  organs.*  ''  ' 

Cruveilhier  subsequently  showed,  that  injuries  affecting  bones, 

* A Patliolngical  Inquiry  into  the  Secondary  Effects  of  Inflammation  of  the  Veins  ’ 
by  James  Arnott,  surgeon.  Medico-Chirurgical  Transac.  Vol.  xv.  p.  i.  London,  1829. 


PATHOLOGY  OF  METASTATIC  ABSCESS  OF  THE  LIVER.  873 


causing  inflammation  of  the  osseous  tissue,  and  involving  the  veins 
of  that  tissue,  are  very  commonly  followed  by  abscess  in  the  liver. 
The  veins  so  aflPected  may  be  so  minute  as  to  escape  notice  ; and 
hence  the  errors  and  misconceptions  that  have  so  long  prevailed  on 
this  subject.  The  experience  of  the  three  days  of  July  1830,  which 
furnished  many  cases  of  gun-shot  wounds  and  injuries  of  bones,  con- 
tributed to  throw  light  on  this  mystery.  It  was  then  found,  that, 
in  some  cases,  injuries  and  fractures  of  the  cranium,  in  other  in- 
stances, compound  fractures  of  the  bones  of  the  extremities,  were 
followed  by  purulent  collections  within  the  liver  ; and  always  almost 
was  it  found,  that  the  veins  of  the  fractured  and  subsequently  in- 
flamed bone  were  inflamed,  and  contained  purulent  matter. 

The  veins  of  bones,  it  must  be  observed,  allow  this  species  of 
suppuration  and  deposit  within  the  liver  more  easily  than  the  veins 
of  other  tissues;  because,  being  contained  within  incompressible 
canals,  they  do  not  collapse,  and  remaining  open,  they  are  more 
likely  to  become  inflamed  than  the  veins  of  other  textures. 

Though  inflammation  and  suppuration  in  the  minute  veins  of 
bones  may  be  generally  requisite,  in  order  to  be  followed  by  second- 
ary purulent  collections,  yet  probably  it  is  not  requisite  that  this 
inflammation  extend  far  up  within  the  venous  trunks  arising  from 
these  minute  veins.  Even  it  may  happen,  that  inflammation  and 
suppuration  of  the  inner  venous  coat  may  not  be  requisite ; and  that 
the  veins  act  as  the  mere  carriers  from  the  inflamed  tissue. 

It  has  been  from  a very  remote  period  observed  that  suppura- 
tion within  the  liver  after  injuries  of  the  head  is  a most  insidious 
affection,  and  takes  place  with  very  imperceptible  external  indica- 
tions of  its  presence ; and  most  probably  this  is  to  be  ascribed  to  the 
circumstance,  either  that  it  is  a peculiarly  chronic  and  insidious 
process,  or  that  it  consists  merely  in  the  successive  transport  of 
purulent  matter  by  the  veins  from  the  parts  suppurating  as  the 
matter  is  formed.  The  testimony  of  Pigray,  given  in  the  middle 
of  the  seventeenth  century,  is  remarkable;  and  its  accuracy  has 
been  confirmed  by  all  subsequent  observers.  “Wounds  of  the 
head,”  he  says,  “are  of  great  importance,  from  the  variety  of 
symptoms  and  accidents  which  follow  them,  which  it  is  good  to 
foresee  and  consider.  In  certain  years,  almost  all  these  wounds, 
both  small  and  great,  are  mortal ; and  this  may  be  ascribed  to  the 
constitution  of  the  air,  of  which  it  is  difficult  to  form  a judgment. 
I remarked  one  year  in  which  wounds  of  the  head,  almost  all, 


874 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


were  followed  by  gangrene  of  two  or  three  fingers’  breadth,  with 
little  fever;  and  nevertheless  few  died.  Several  others  I have 
seen,  in  which  no  manifest  accidents  followed ; and  nevertheless 
there  died,  namely,  of  the  smallest  wounds,  principally  those  in 
whom  fever  began  the  third  day  after  the  infliction  of  the  wound ; 
but  in  almost  all  those  who  so  died,  we  found  a purulent  abscess 
in  the  substance  of  the  liver.”* 

This  insidiousness  led  Bertrandi  to  observe,  that  the  writers  by 
whom  these  instances  of  hepatic  suppuration  after  injuries  of  the 
head  are  recorded,  were  unaware  of  the  existence  of  such  collec- 
tions in  the  liver  before  the  body  was  inspected. 

Without  dwelling  longer  on  this  subject,  I only  add,  that  it  is 
not  impossible  that  in  several  cases  the  operation  of  trepanning 
itself,  by  inducing  inflammation  of  the  bone,  may  have  been  a 
cause  of  hepatic  suppuration. 

5.  Instances  of  purulent  collection  or  collections  within  the 
liver,  in  consequence  either  of  inflammation  of  the  veins  of  the 
intestines,  or  of  these  veins  opening  at  purulent  surfaces,  are  often 
observed.  Cruveilhier  mentions  a case  in  which  a man  of  60  had 
a protruded  rectum  replaced,  after  repeated  and  violent  attempts, 
which  caused  much  pain.  He  speedily  became  ill,  with  the  usual 
symptoms  indicating  disease  of  the  veins,  and  on  the  fifth  day 
expired.  Several  small  abscesses,  superficial  and  deep-seated,  were 
found  within  the  liver.  In  other  instances,  the  puriform  collec- 
tions were  formed  after  operations  on  the  rectum,  where  the  actual 
cautery  was  employed  ; after  the  operation  for  the  cure  of  fistula 
ani ; and  after  that  for  strangulated  hernia,  in  which  a portion  of 
irreducible  omentum  underwent  suppuration,, 

It  is  not  easy  to  say  whether  in  these  instances  suppuration 
within  the  veins  is  always  necessary  ; or  whether  the  veins  merely 
transport  the  purulent  matter  to  the  liver.  Inflammation  is  sel- 
dom found  to  extend  far  from  the  spot ; and  almost  never  into  the 
interior  of  the  large  veins.  It  is  probable  that  when  hepatic 
abscess  takes  place  after  ulceration  of  the  intestinal  canal,  it  is 
rather  to  the  transporting  power  of  the  veins  than  to  their  actual 
inflammation,  that  this  sym-phenomenon  is  to  be  ascribed. 

Of  twenty-nine  instances  of  this  conjunction  given  by  Annesley,  ' 
in  twenty-one,  or  nearly  three-fourths,  were  these  ulcers  more  or 

* Epitome  des  Pieceptes  de  Medecine  et  Chirurgie.  Par  Pierre  Pigray.  A Rouen, 
1658.  12mo.  Liv.  iv.  chap.  ix.  p.  368. 


PATHOLOGY  OF  METASTATIC  ABSCESS  OF  THE  LIVER.  875 


less  extensive  in  the  large  intestine ; and  in  other  two  cases  the 
colon  was  contracted  with  stricture,  showing  the  presence  of  dy- 
sentery at  some  former  period.  Among  fifteen  fatal  cases  which 
fell  under  the  observation  of  Dr  Budd  in  the  Dreadnought,  in  eight 
cases  there  were  ulcers  in  the  large  intestines ; in  one  case,  two 
ulcers  were  observed  in  the  stomach  ; and  in  two  cases  the  state  of 
the  intestines  was  not  observed  ; so  that  in  nine  among  thirteen  cases 
hepatic  abscess  was  conjoined  with  ulcers  in  the  colon  or  stomach. 
Among  sixteen  cases  collected  by  Andral  and  Louis,  in  two  cases 
ulcers  in  the  large  intestine  and  lower  end  of  the  ileum  are  noticed  ; 
in  one  case,  ulcers  were  observed  in  the  lower  end  of  the  ileum 
only ; in  four  cases,  ulcers  were  seen  in  the  stomach ; and  in  one 
case,  in  the  gall-bladder.  In  one  of  these  cases  of  ulcer  of  the 
stomach,  the  ulcer  was  caused  by  the  abscess  opening  into  the  sto- 
mach ; and  this  case  may  therefore  be  excluded.  With  this  de- 
duction, however,  there  are,  among  fifteen  cases,  seven  in  which  the 
existence  of  abscess  of  the  liver  was  preceded  by  ulceration  of  some 
part  of  that  extensive  mucous  membrane,  from  which  the  capillary 
veins  arise  and  proceed  to  unite  in  the  vena  portae. 

I have  already,  in  page  863,  mentioned  that,  in  1827,  I met 
with  a remarkable  example  of  the  conjunction  of  large  hepatic 
abscess,  with  extensive  ulceration  of  the  colon;  and  in  which 
the  formation  of  the  former  was  so  insidious,  that  its  existence  was 
not  suspected  during  life.  It  appeared  to  me  at  this  time  that 
some  connection  between  the  two  phenomena  subsists ; and  that  this 
connection  is  not  accidental.  Of  this  connection  I had  little  doubt, 
after  reading  the  Memoir  of  Mr  Arnott,  already  referred  to  ; and 
if  I had,  that  doubt  must  have  been  removed  by  the  facts  given  in 
1833  by  Cruveilhier.* 

On  the  other  hand,  it  is  agreed,  that,  in  the  case  of  this  sym- 
phenomenon,  in  various  instances  hepatic  suppuration  precedes  the 
formation  of  ulcers  of  the  intestinal  canal.  This,  however,  merely 
shows,  that  the  same  general  causes  which  produce  hepatic  abscess, 
that  is,  excessive  solar  heat,  terrestrial  miasmata,  and  full  living, 
may  be  followed  by  inflammatory  processes  in  two  sets  of  organs 
much  exposed  to  the  hurtful  influence  of  these  physical  causes. 

It  must  also  be  observed,  that,  for  aught  that  is  hitherto  known, 
mere  inflammation,  or  even  vascular  congestion  of  the  mucous 
membrane  of  the  alimentary,  may,  considering  the  direct  relation 

* Anatomie  Pathologique,  Livraison  xi.  pi.  1,2,  3.  Paris,  1833. 


876 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


of  its  venous  system  with  that  of  the  liver,  give  rise,  in  the  latter  ‘ 
organ,  tojrritation,  which  might  readily  terminate  in  suppuration.  ^ 

Physicians  in  India,  where  this  union  is  most  commonly  seen, 
ascribe  the  dysenteric  disorder  to  the  passage  of  irritating  hile.  i 

Were  this  always  the  case,  then  it  ought  to  be  expected  that  the  * 

small  intestine  should  be  diseased  before  the  large  intestine.  This, 
however,  is  so  far  from  being  the  case,  that  most  commonly  the 
colon  is  first  diseased ; and,  in  many  cases,  the  colon  alone  is  ulce- 
rated, while  the  ileum  remains  sound.  The  bile,  if  it  irritate,  must 
irritate  most  the  membrane  which  it  touches  first ; and,  before  it 
reaches  the  colon,  its  irritative  properties  ought  to  be  abated,  if  not 
extinguished.  Yet  the  effects  of  this  irritation  are  presented  in  no 
degree  almost  by  the  small  intestine,  and  in  a most  remarkable  de- 
gree by  the  large  intestine.  From  these  facts,  it  seems  natural  to 
infer,  that  whatever  be  the  cause  of  ulceration  in  the  colon,  it  is  not 
irritating  bile  ; that  the  blood  sent  from  the  diseased  intestinal  mu- 
cous  membrane  irritates  through  the  branches  of  the  portal  vein  the 
substance  of  the  liver. 

§ 3.  Sphakelus — Gangrene  of  the  Liver. — Gangrene  of  the 
liver  is  a rare  affection  ; and  we  must  be  cautious  in  admitting,  as 
examples  of  the  lesion,  all  the  instances  given  by  authors.  In  the 
majority  of  cases,  from  Morgagni  downwards,  the  descri[)tions  are 
too  vague,  and  merely  represent  portions  of  the  liver  to  be  in  a state 
of  sphakelus.  The  lesion  nevertheless  may  take  place  ; first,  either 
by  gangrene  attacking  an  abscess  of  the  liver,  generally  with  more 
or  less  inflammation  of  the  veins  ; and,  secondly,  in  consequence  of, , - 
or  in  connection  with,  gangrene  of  some  part  of  the  surface,  for  in-'^ji 
stance,  the  toes  or  the  sacrum,  and  the  gangrenous  inflammation^Tfll 
passing  thence,  apparently  by  the  veins,  either  to  the  liver  or  the^Bl 
lungs,  or  to  both  simultaneously.  jH  j 

In  the  former  case,  a large  portion  or  the  whole  of  the  walls  of^y] 
an  abscess  are  soft,  flaccid,  and  filamentous,  exhaling  an  offen-  S 
sive  odour,  while  the  adjoining  portion  of  liver  is  also  more  or  less 
softened,  dark  coloured,  and  lacerated.  In  the  latter  case,  the  ^ 
lesion  appears  in  the  form  either  of  one  gangrenous  abscess,  that  is,  ‘ 
an  abscess  with  soft,  ragged,  dark  brown  fetid-smelling  walls;  or  * , 
in  the  shape  of  several  collections,  of  the  same  characters,  while  the 
neighbouring  veins  contain  fetid  purulent  matter.  Y, 

Gangrene  of  the  liver  is  occasionally  associated  also  with  gan- 
grene of  the  lungs. 


4 


877 


GANGRENE  OF  THE  LIVER. 

The  cause  of  this  lesion  is  not  well  understood.  Are  we  to  be^ 
lieve  that  it  is  an  affection  originally  gangrenous  ? or  are  we  to 
believe  that  the  gangrenous  termination  is  an  effect  of  inflamma- 
tion ? To  me,  it  appears  to  be  the  result  rather  of  inflammation  of 
peculiar  intensity,  in  persons  of  a certain  kind  of  constitution,  than 
of  a gangrenous  form  of  inflammation.  The  course  of  phenomena, 
or  rather  of  the  process,  seems,  in  general,  in  cases  of  this  nature, 
to  be  as  follows.  First,  inflammatory  action  or  vascular  congestion 
distends  and  overloads  the  vessels  of  the  part,  and  causes  interstitial 
extravasation  of  blood,  of  lymph,  and  of  serum  ; secondly,  by  this 
the  tenacity,  pliancy,  and  elasticity  of  the  texture  are  destroyed ; 
it  becomes  friable,  lacerable,  and  easily  softened ; its  physical  pro- 
perties are  altered  and  impaired ; and  its  vital  properties  are  en- 
feebled ; thirdly,  as  this  action  or  inaction  continues,  the  texture  of 
the  part  is  still  more  completely  changed  from  its  normal  state ; 
and  at  length,  on  any  slight  increase  in  the  morbid  distension,  the 
parts,  already  deprived,  in  a great  degree,  of  their  vital  pro- 
perties, give  way ; vessels  are  broken  open,  and  expose  their  con- 
tents ; parts  lose  their  cohesion  ; and  the  process  of  gangrene, 
which  is  a mixture  of  the  mechanical  with  the  weak  vital,  is  esta- 
blished. 

On  the  other  hand,  gangrenous  suppuration  of  the  liver  may 
follow  the  formation  of  an  external  gangrenous  sore. 

In  the  collection  of  pathological  drawings  made  by  the  late  Dr 
Thomson,  is  an  instance  in  several  respects  important.  A person 
attempted  to  destroy  himself,  first,  by  cutting  his  throat,  and  after- 
wards by  discharging  a pistol  at  his  forehead.  Death  did  not  ensue 
immediately.  The  wound  of  the  throat  mortified ; and  exfoliation 
from  the  frontal  bone  took  place.  After  death,  which  took  place 
in  about  ten  days,  a large  abscess,  with  ragged,  dark-coloured, 
softened  walls,  was  found  in  the  upper  part  of  the  right  lobe  of 
the  liver.* 

In  this  remarkable  case,  we  observe  the  illustration  of  two  pa- 
thological principles,  which  I have  attempted  to  establish.  First,  the 
abscess  in  the  liver  was  evidently  secondary,  and  consecutive  either 
on  the  wound  in  the  frontal  bone,  or  on  that  in  the  throat,  most 
likely  the  former.  The  suppurating  process  in  the  medullary  mem- 
brane of  the  frontal  bone,  rendered  necessary  to  eject  the  dead 

* A Practical  Treatise  on  Diseases  of  the  Liver  and  Biliary  Passages.  By  William 
Thomson,  M.D.,  and  the  private  collection  of  that  gentleman. 


878  GENERAL  AND  PATHOLOGICAL  ANATOMY. 

bone  and  lieal  the  living  one,  gave  rise  to  the  formation  of  matter,  j 
which  was  conveyed  by  the  vessels  of  the  bone  by  the  veins  to  the 
liver.’  Secondly^  as  this  purulent  collection  was  then  forming 
within  the  liver,  it  was  struck  with  sphakelus,  most  likely  in  conse- 
quence of  the  previous  mortified  and  sloughing  state  of  the  wound 
in  the  throat. 

Tt  is  necessary  to  distinguish  gangrene  of  the  liver  from  those 
changes  in  colour, — blue,  black,  dark-green,  dark-brown,  mottled 
dark-green  and  brown,  which  are  so  common  in  this  organ.  These 
colours  are  effects  of  mere  death  changes.  No  change  in  colour, 
without  an  evident  change  in  consistence  and  demolition  of  struc- 
ture, can  be  received  as  indicating  the  presence  of  gangrene. 

It  has  been  supposed  that  hemorrhage  may  be  the  cause  of  gan- 
grene. It  seems  rather  the  effect  in  the  majority  of  cases. 

§ 4.  Malakosis. — Softening  of  the  Liver  has  been  observed, 
in  certain  circumstances,  to  take  place.  The  substance  of  the  liver 
is  then  soft,  friable,  easily  torn  and  broken  down  between  the  fin- 
gers ; and,  in  some  instances,  the  change  in  cohesion  is  so  great, 
that  the  hepatic  substance  resembles  softened  spleen. 

Dr  Marshall  met  in  Ceylon  with  instances  of  softening  of  the 
liver  without  other  remarkable  change.  In  other  instances  the 
parenchyma  was  granular,  and  broke  down  between  the  fingers, 
while  the  peritoneal  coat  came  away  with  unusual  facility.  He 
mentions  one  case  in  which  the  liver  was  softened  in  such  a man- 
ner in  a patient  with  dysentery,  that  the  pulpy  substance  resembled 
hasty  pudding.  The  liver  weighed  in  this  case  pounds — more 

than  double  the  average.  In  all  such  cases  the  softening  is  the 
effect  of  a species  of  vascular  congestion  or  orgasm. 

Of  this  lesion,  Andral  distinguishes  two  varieties, — one  indi- 
cated by  the  red  colour  of  the  hepatic  substance ; the  other  by  a 
pale  or  whitish  colour.  In  the  former,  the  substance  presented  th^„  , 
appearance  of  softened  spleen  ; in  the  latter,  of  a species  of  gray^ 
coloured  pap,  and  with  little  blood  in  the  tissue.  In  the  former 
case,  the  softening  appeared  to  be  the  effect  of  inflammation  of  the  [ 
peritoneum,  general  and  hepatic.  In  the  latter  case,  it  appeared 
to  be  the  result  of  lesion  of  nutrition  ; as  the  gall-bladder  contained 
not  bile,  but  colourless  and  insipid  serum.  The  latter  also  appears 
to  be  more  chronic  in  its  progress  and  duration  than  the  former.* 

§ 5.  Hepatic  Phlebitis Inflammation  of  the  veins  of  the  liverijtf 

is  not  very  frequent ; and  when  abscesses  and  purulent  collectionsj* 

* Case  by  M.  Snetiwy.  Oesterreich.  Med.  Wochenschrift.  1842.  N.  32.  8S,' 


HEPATIC  PHLEBITIS. 


879 


are  found  within  the  gland,  these  are  the  result  either  of  inflamma- 
tion of  the  parenchyma  or  of  the  transporting  property  of  the  veins, 
which,  however,  themselves  remain  unafiected.  Inflammation  may 
nevertheless  aflFect  veins  either  spontaneously  or  from  the  irritation 
of  foreign  bodies. 

M.  Lambron  records  the  case  of  a man  of  69  who  was  attacked 
with  squeamishness,  sickness,  uneasiness  in  the  right  hypochondre, 
and  irregular  shiverings.  In  the  course  of  four  days,  jaundice  ap- 
peared slightly,  and  increased  in  the  subsequent  three  days.  At 
the  end  of  one  week,  the  shiverings,  which  had  not  been  very  dis- 
tinct, were  present  in  the  evening,  generally  with  hiccup,  and  imi- 
tated the  rigors  of  ague.  The  symptoms  continued  with  great 
and  increasing  weakness  ; and  the  patient  expired  on  the  25th  day 
from  the  appearance  of  well-marked  symptoms. 

Inspection  revealed  the  following  state  of  parts.  The  portal  vein 
was  filled  with  wine-lee  matter  and  purulent  matter ; in  the  trunk 
of  the  superior  mesenteric  vein  a fish-bone,  which,  implanted  in 
the  head  of  the  pancreas,  had  entered  the  anterior  wall  of  this  vein 
from  before  backwards,  and  was  fixed  in  the  posterior  wall  of  the 
same  vein.  This  bone  was  about  3 centimetres,  or  one  inch  and  a 
little  more  than  a line  long  ; as  thick  as  a stout  pin ; yellowish,  hard, 
and  resisting ; and  the  extremity  was  twisted  like  a cork-screw.  The 
cavity  of  the  mesenteric  vein  was  obliterated  by  slate-gray  false  mem- 
brane. Below  this  obliteration  the  divisions  of  the  superior  mesente- 
ric were  sound,  but  contained  fibrinous  clots  of  blood.  The  splenic 
vein  was  in  size,  colour,  and  consistence  normal ; but  it  contained 
a quantity  of  wine-lee  coloured  matter ; and  the  same  matter  was 
found  in  the  divisions  of  the  portal  vein,  while  its  sinus  was  filled 
with  purulent  matter  mixed  with  blood.  The  liver  presented  no 
metastatic  abscess ; but  its  tissue  at  the  level  of  the  portal  sinus 
was  very  much  softened.  The  sub-hepatic  veins  were  sound.* 

The  same  observer  gives  the  case  of  a man  of  48,  who  had  been 
ill  for  eight  days  with  debility,  slight  fever,  and  was  incoherent 
at  admission.  Four  days  after  he  had  violent  and  distinct  rigors ; 
while  it  was  observed  that  the  size  of  the  spleen  was  palpably 
enlarged.  The  rigors  underwent  temporary  abatement;  but 

* Observations  d’Inflammation  de  Veines  du  Foie.  Imo,  de  la  Veine-Porte  pro- 
duite  par  une  arete  de  poisson  ; 2do,  des  veines  sus-hepatiques,  due  au  voisinage  d’un 
abces  metastatique.  Par  Ernest  Lambron.  Archives  Generates.  Juin  1842.  Tom. 
lix.  p.  129. 


880 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


without  improving  the  condition  of  the  patient ; and  in  rather  more 
than  three  weeks  they  returned,  accompanied  with  delirium,  fol- 
lowed by  profuse  sweatings  and  diarrhoea.  In  ten  days  more 
death  followed,  the  whole  duration  of  the  illness  having  been 
about  73  days. 

At  the  pyloric  end  of  the  stomach  was  an  ulcerated  cancer, 
which  had  destroyed  the  mucous  membrane  to  the  extent  of  more 
than  a shilling.  The  liver  was  in  size  normal,  but  yellowish,  and  as 
if  fatty ; and  part  of  it  was  dotted  with  red  points,  which  were  traced 
to  the  inter-lobular  veins.  Disseminated  in  the  hepatic  substance 
were  seven  or  eight  purulent  collections,  which  looked  like  metas- 
tatic abscesses.  The  largest  of  these  was  the  size  of  a hen’s  egg. 
One  of  these  abscesses  was  situate  near  one  of  the  trunks  of  the 
sub-hepatic  veins,  as  they  enter  the  vena  cava,  where  that  vessel  is 
attached  to  the  base  of  the  lobule  of  Spigelius.  This  abscess  had 
caused  inflammation  in  the  venous  trunk,  so  that  the  latter  showed, 
at  some  lines  from  its  opening  into  the  vena  cava,  an  ulceration  about 
eight  millimetres  (/g  of  one  inch)  in  diameter,  while  matter  easily 
flowed  from  the  abscess  into  the  cavity  of  the  vessel.  The  portion 
of  the  vein  between  the  ulceration  and  the  vena  cava  was  quite 
covered  with  lymph  sufiiciently  thick  to  protect  the  interior  of  the 
vein  from  the  entrance  of  the  purulent  matter.  Above  the  ulcera- 
tion the  vessel  was  intensely  inflamed ; and  its  area  was  obliterated 
by  lymph  and  fibrinous  clots.  The  circulation  was  thus  completely 
interrupted.* 

This  disease  is  generally  fatal.  Yet  I have  stated  in  a former 
part  of  this  work,  (p.  127,)  that  I have  met  with  a case  in  which 
the  trunk  of  the  portal  vein,  together  with  those  of  the  splenic 
and  superior  mesenteric  veins,  were  completely  filled  and  obstructed 
by  a solid  coagulum  of  lymph  apparently,  or  lymph  with  fibrin  of 
blood. 

In  this  case  it  is  probable  that  the  obstruction  or  closure 
of  the  vein  in  this  manner  must  have  arisen  from  one  of  two 
causes ; either  inflammation  within  the  vein,  or  pressure  exter- 
nally. If  the  former  were  the  cause,  then  the  closure  was  perhaps 

* These  cases  have  since  been  quoted  in  a German  journal,  in  order  to  prove  that 
splenic  inflammation  and  enlargement  is  the  primary  cause  of  intermittent  fever,  not 
the  effect ; and  in  order  to  accomplish  this,  the  speculator  has  added  to  the  report  of 
the  first  case,  that  the  spleen  was  strongly  developed  and  distinctly  circumscribed,  and 
in  the  second,  that  its  volume  was  evidently  increased. 


HEPATIC  HEMORRHAGE, 


881 


one  means  of  averting  the  immediate  fatal  termination.  In  this 
person  further,  the  right  lohe  of  the  liver  was  so  much  shrunk 
and  diminished,  that  the  whole  organ  weighed  only  about  one- 
fourth  of  its  usual  amount ; while  its  shape  was  greatly  altered, 
being  rounded  and  drawn  from  the  sides  and  circumference  to  the 
centre ; so  that  the  whole  gland  was  represented  by  a small  shrunk 
left  lobe.  The  effect  of  this  lesion,  which  is  one  species  of  atrophy, 
was  obstinate  and  incurable  ascites. 

§ 6.  Hepatorrhagia. — I am  quite  satisfied  that  occasionally 
the  biliary  ducts  and  the  liver  pour  out  blood,  which  is  discharged 
into  the  intestinal  canal.  I have  more  than  once  seen  in  patients 
large  quantities  of  blood-coloured  bile,  and  even  blood  discharged 
in  this  manner,  which  I am  satisfied  came  from  the  biliary  ducts 
and  the  port  biliarii^  in  which  this  liquid  had  been  poured  out 
abundantly.  This  is  a species  of  hepatic  haemorrhage. 

Another  variety,  however,  of  hepatic  haemorrhage  takes  place, 
one  in  which  blood  is  poured  into  the  substance  of  the  liver,  which 
is  rent  and  lacerated,  much  as  is  the  brain  in  apoplexy.  Sir  G. 
Blane  gives,  in  a boy  of  eight,  a case  in  which,  after  eight  days  of 
illness,  ending  fatally,  several  fissures  were  found  in  the  left  lobe  of 
the  liver,  and  much  blood  was  effused  within  the  abdomen.*  M. 
Andral  mentions  the  case  of  a person  who,  without  any  previous 
complaint  or  indication  of  illness,  felt  one  morning  on  awaking, 
pains  in  the  abdomen,  and  accordingly  remained  in  bed.  In  the 
course  of  a few  hours  he  was  found  dead.  The  peritoneal  cavity 
was  filled  with  a large  quantity  of  dark-coloured  blood  partly 
coagulated ; and  several  clots  were  found  between  the  diaphragm 
and  the  convex  surface  of  the  liver.  Near  the  centre  of  the  right 
lobe,  on  the  convex  surface,  was  an  opening  of  sufficient  size  to 
admit  the  tip  of  the  little  finger,  and  which  was  the  orifice  of  a 
cavity  in  the  hepatic  substance  as  large  as  a pippin,  and  filled 
with  blood.  A large  vessel  which  had  been  rent  opened  on  a 
point  in  this  cavity ; and  this  vessel  was  found  to  be  a branch  of 
the  portal  vein.  The  surrounding  parenchyma  was  healthy.f 

Dr  Honore  presented,  in  1 834,  to  the  Academy  a liver,  in  which 
were  several  cavities  containing  blood.  It  was  uncertain,  however, 
whether  this  proceeded  from  torn  vessels  or  was  the  effect  of  exha- 
lation. 

M.  Louis  mentions  one  case  in  which,  along  with  an  abscess, 

* Transactions  of  a Society,  Vol.  ii.  p.  18.  London,  1800. 

t Medecine  Clinique.  Partie  Vieme.  Livre  Ilieme.  Set.  1.  chap.  iii. 

3 K 


882 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


there  was  in  the  liver  a cavity  as  large  as  a nut,  containing  blood 
coagulated  in  concentric  layers.  No  laceration  in  any  of  the  blood- 
vessels was  recognized. 

Instances  of  this  lesion  have  been  given  also  by  Dr  Heyfelder 
and  Dr  James  Abercrombie.  In  the  former  case,  which  took  place 
in  a man  of  60,  the  heart  was  affected  with  hypertrophy  of  the 
right  ventricle,  and  the  rent,  which  was  in  the  right  lobe  of  the 
liver,  communicated  with  the  laceration  in  the  portal  vein.*  In  the 
latter,  which  occurred  in  a lady  of  35,  who  had  been  several  years 
in  India,  the  liver  presented,  at  its  anterior  and  upper  surface,  a 
large  sac,  containing  two  pounds  of  blood.  This  sac  was  the  peri- 
toneum. The  blood  had  escaped  from  a branch  of  the  portal  vein. 
The  accident  occurred  in  the  eighth  month  of  pregnancy.  The 
liver  was  softened,  lacerable,  and  pulpy.f 

The  causes  of  this  lesion  and  its  external  effects  are  equally  un- 
known. 

In  those  affected  with  scurvy,  the  liver,  as  other  organs,  is  liable 
to  present  effusions  of  blood,  which, *in  this  case,  undergoes  imper- 
fect coagulation. 

§ 7.  Traumatic  Laceration  and  Hepatorrhagia. — In  falls 
from  a considerable  height,  especially  on  hard  ground,  and  after 
death  by  heavy  bodies  which  have  passed  over  the  trunk,  laceration 
and  hemorrhage  of  the  liver  is  by  no  means  uncommon.  On  the 
1st  of  January  1824,  three  soldiers,  in  attempting  to  get  out  of 
Edinburgh  Castle,  mistook  their  way  in  the  dark,  and  fell  over  the 
perpendicular  side  of  the  rock.  They  were  found  dead  next  morn- 
ing ; and  in  all  the  liver  was  lacerated. 

Cases  of  rent  either  from  violence  or  falls  are  given  by  Morgagni 
and  Dr  Pearson  and  instances  of  the  same  accident  from  the 
transit  of  a carriage  or  waggon  over  the  trunk  or  abdomen  are 
given  by  various  authors. 

In  all  these  cases,  hemorrhage  to  a greater  or  less  extent  takes 
place  ; and  as  the  blood  flows  into  the  cavity  of  the  perito- 
neum, if  life  be  not  immediately  or  speedily  extinguished,  the  quan- 
tity may  be  estimated  by  the  degree  of  swelling  which  takes  place,' 
with  the  dull  sound  always  emitted  on  percussion,  when  blood  is 
contained  within  the  abdominal  cavity. 

* Memoire  sur  plusieurs  Maladies  du  Foie.  Par  Dr  Heyfelder.  Archives  Gene- 
rales,  t.  li.  p.  468.  Paris,  1839. 

■f  London  Medical  Gazette,  September,  1844,  Vol.  xxxiv.  p.  507  and  p.  792.  One 
case  twice  given. 

+ Transactions  of  College  of  Physicians,  vol.  in.  art.  xxiv.  p.  377.  London,  1785. 


HYPERTROPHY  OF  THE  LIVER. 


883 


Death  is,  in  these  cases,  generally  immediate,  or  at  most  follows 
in  no  long  time.  A young  boy  of  five  or  six  was  crossing  the  street 
at  the  South  Bridge,  about  two  o’clock  in  the  day.  He  was 
knocked  down  some  way  by  a carriage  passing,  and  one  if  not  both 
wheels  passed  over  the  trunk  before  the  coachman  could  stop  his 
horses.  The  boy  was  taken  up  immediately  and  brought  to  the 
Infirmary,  where  I was  at  the  time.  He  was  quite  dead ; and  it 
was  manifest,  from  the  appearance  of  the  abdomen,  which  was  al- 
ready enlarged,  that  blood  was  copiously  escaping  into  its  cavity. 
When  the  body  was  examined  next  day,  it  was  found  that  the  liver 
had  been  much  crushed,  and  had  not  only  been  rent  across  the 
right  lobe,  but  as  if  broke  down.  About  four  or  four  pounds  and  a 
half  of  blood  in  clots  and  fluid  were  found  in  the  abdominal  cavity. 

My  limits  do  not,  however,  allow  me  to  say  more  of  these  cases, 
nor  of  the  important  order  of  wounds  of  the  liver,  for  information 
on  which  I refer  to  the  writings  of  military  surgeons. 

§ 8.  Hypertrophy By  hypertrophy  is  meant  increase  of  the 

liver  in  size  and  weight,  without  any  palpable  change  in  structure. 
The  normal  weight  of  the  liver  varies  at  different  ages,  in  the  two 
sexes,  and  according  to  the  size  and  stature  of  the  individual.  In 
general,  in  an  adult  of  between  25  and  35  years  of  age,  and  of  the 
height  of  5 feet  8 inches,  the  liver  will  weigh  about  three  lbs.,  anA 
from  two  to  six  ounces  imperial  weight,  or  about  53  ounces.  In 
general,  it  may  be  stated  that  the  weight  of  the  liver  is  between  the 
29th  and  30th  part  of  the  weight  of  the  whole  person.* 

* Facts  and  Inferences  relative  to  the  Condition  of  the  Vital  Organs  and  Viscera  in 
general,  as  to  their  Nutrition  in  certain  Chronic  Diseases.  By  John  Clendinning, 
M.  D.,  &c.  Medico-Chirurgical  Transactions,  vol.  xxi.  p.  33.  London,  1838. 

Mr  Marshall  gives  several  important  facts  regarding  the  weight  of  the  liver  in  the 
troops  in  Ceylon.  Of  55  livers  belonging  to  Europeans  that  died  of  fever,  25  were 
deemed  sound.  The  average  weight  of  these  livers  was  4 pounds  6 ounces.  The  ex- 
tremes were  6 pounds  and  3 pounds  7 ounces.  27  appeared  unusually  soft.  The 
average  weight  of  this  division  was  4 pounds  IS  ounces.  The  largest  weighed  6 pounds 
8 ounces  ; the  smallest  3 pounds  1 3 ounces.  Two  were  found  indurated.  One  weigh- 
ed 2 pounds  10  ounces  ; the  other  10  pounds.  Mr  Marshall  states  afterwards,  that 
of  two  examples  of  indurated  liver,  in  which  the  gland  cut  hard  and  gritty  under  the 
knife,  and  in  both  of  which  the  liver  was  rounded  or  drawn  together  like  a ball, 
without  any  of  the  usual  distinctions  into  lobes,  one  weighed  3 pounds,  the  other  4 
pounds.  [This  is  hi'irhosis.']  He  adds,  that  “ the  livers  of  European  soldiers  were 
found  to  vary  in  weight  from  2J  pounds  to  5 pounds,  without  any  satisfactory  trace 
of  pre-existing  disease.” — Notes  on  the  Medical  Topography  of  the  Interior  of  Ceylon. 
By  Henry  Marshall,  Surgeon  to  the  Forces.  London,  1821.  P.  141,  and  151  and  152. 

These  numbers  are  higher,  on  the  whole,  than  those  which  we  have  been  accustom- 
ed to  observe  in  this  country.  I have  weighed  a great  number  of  livers  at  the  Royal 


884 


GENERAL  AND  PATHOLOGICAL  ANATOMY, 


Above  this  standard  the  weight  of  the  liver  may  rise  greatly ; 
for  instance,  to  G,  8,  9,  or  even  10  pounds;  and  its  volume  is  pro- 
portionally increased.  At  the  same  time,  the  organ  is  in  a high 
degree  vascular,  firmer  than  natural,  and  cuts  hard  under  the  knife. 
The  intimate  structure  is  generally  understood  not  to  be  impaired,  or 
in  any  way  changed ; and  in  one  sense  this  is  correct.  The  structure 
resembles,  except  in  increased  firmness  and  greater  vascularity,  the 
usual  structure  of  the  liver;  yet,  when  examined  carefullyand  closely, 
the  granular  tissue  of  the  organ  appears  more  fleshy  than  in  the  nor- 
mal state,  and  occasionally  portions  of  the  liver  are  harder  than  the 
surrounding  texture.  In  certain  periods  of  the  disease,  which  I 
supposed  must  be  more  advanced,  the  vascularity  of  the  organ  ap- 
])ears  diminished ; at  least  less  blood  escapes  from  incisions. 

The  increase  in  volume  which  the  liver  acquires,  when  enlarged 
hy  hypertrophy,  may  be  very  considerable,  and  with  its  increase  in 
weight,  produces  great  uneasiness  and  derangement  in  some  of  the 
thoracic  and  all  the  abdominal  visce^’a.  The  gland  is  enlarged  in 
all  its  dimensions,  and  may  press  up  the  right  side  of  the  diaphragm 
and  right  lung,  wliile  it  prevents  the  diaphragm  from  descending 
freely.  It  also  thrusts  upward  the  tendinous  centre  and  the  heart  a 
little.  These  effects,  nevertheless,  vary  according  to  the  posture  of 
the  patient.  Thus,  in  the  horizontal  position,  the  hypertrophied 
liver  is  decidedly  higher  up  in  the  right  side  of  the  chest  than  in 
the  erect.  In  the  latter,  while  its  bulk  prevents  the  free  descent 
of  tlie  diaphragm,  its  weight  draws  that  muscle  downward.  In  the 
abdomen  it  may  come  down  as  low  as  the  crest  of  the  os  ilium^ 
while  at  the  same  time  it  extends  beyond  the  median  line  into  the  left 
hypochondriac  region,  and  makes  usually  a decided  bulging  pro- 
minence in  the  right  hypochondriac  and  epigastric  regions.  From, 
the  circumstance  of  the  liver  lying  transversely  below  the  diaphragm, 
this  bulging  is  generally  more  marked  above  than  below,  the  gland* 
being  tied  closely  to  the  diaphragm  by  its  ligaments.  ' 

The  hypertrophied  liver  usually  has  contracted  preternatural  ad- 
hesions with  the  neighbouring  organs;  the  stomach;  the  transverse 

Infirmary,  and  generally  found  those  supposed  to  be  free  from  disease  to  be  from  ?j 
jiounds  to  d pounds  5 or  6 ounces.  Very  rarely  did  they  ascend  to  4 pounds, 
unless  in  conjunction  with  jialpable  marks  of  disease.  In  females,  the  weight  was 
usually  about  2 pounds  10  ounces  to  3 pounds.  One  fatty  liver  in  a young  female 
(lead  of  consumption  I found  to  weigh  8 pounds  and  7 or  8 ounces.  The  low  weight 
of  the  liver  given  by  Mr  Marshall  is  less  astoni.shing  than  the  high  weight  within  tlie 
limits  of  healthy  structure.  These  weighty  livers  were  probably  hypertrophied. 


HYPERTROPHY  OP  THE  LIVER. 


885 


arch  of  the  colon;  the  duodenum,  or  the  pancreas,  or  cdl  these  at 
the  same  time. 

Instances  of  hypertrophy  of  the  liver  have  been  long  observed. 
They  were  seen  by  Morgagni,  Bianchi,  Bang,  Stoll,  Portal,  Fo- 
dere,  Baillie,  Bailly,  and  all  who  have  observed  the  morbid  changes 
incident  to  this  gland.  The  lesion  is  at  present  common  in  differ- 
ent forms  and  degrees. 

Hypertrophy  may  be  the  effect  of  the  third  variety  of  inflamma- 
tion, the  acute,  congestive,  or  enlarging.  But  more  commonly  it 
advances  slowly  and  steadily,  until  the  size  of  the  organ  and  its 
projection  under  the  right  hypochondriac  margin  and  the  epigas- 
tric region  renders  the  enlargement  no  longer  doubtful.  As  it 
advances,  it  gives  rise  to  effusion  of  serous  fluid  within  the  abdo- 
men. 

Hypertrophy,  both  in  moderate  and  extreme  degrees,  arises  in 
this  country  from  the  intemperate  and  long  continued  use  of  spirits. 
One  of  the  most  marked  instances  of  the  disease  which  have  come 
under  my  notice,  in  which  th^  liver  projected  fully  four  inches  be- 
low the  margin  of  the  right  hypochondre,  arose  in  this  manner. 
When  first  seen,  it  was  in  the  early  stage,  with  symptoms  of  inflam- 
matory and  vascular  congestion.  Under  the  use  of  remedies 
chiefly  depleting,  the  size  of  the  organ  was  reduced,  and  the  drop- 
sical effusion  within  the  peritoneum  disappeared.  But  when  the 
patient  left  the  hospital,  he  returned  to  his  previous  habits,  and  in 
no  long  time  came  back,  with  the  liver  as  large,  heavy,  and  pro- 
minent as  before.  He  soon  sunk  under  the  disease.  The  liver 
was  found  to  weigh  upwards  of  10  pounds. 

Instances  of  the  disease  I have  seen  come  from  Norfolk,  in  some 
parts  of  which  county  it  is  the  effect  either  of  ague  or  the  physical 
causes  of  that  disease.  The  change  has  also  been  observed  in  all 
aguish  and  marshy  districts ; in  Lincolnshire  and  some  parts  of 
Essex  in  England ; in  the  department  of  the  Maritime  Alps,  ac- 
cording to  Fodere;  in  the  island  of  Walcheren  and  many  parts 
of  Holland ; in  the  Maremma  in  Italy ; in  the  marshy  and  low  coasts 
of  the  W est  India  Islands ; and  in  various  parts  of  the  East  Indies. 
In  these  situations,  hypertrophy  of  the  liver  may  either  follow  one 
or  more  attacks  of  ague,  most  usually  quartan  ague,  or  it  may  be 
established  slowly  and  steadily  without  being  preceded  by  any  dis- 
tinct attack  of  this  disease.  In  these  circumstances,  it  is  clear  that 
the  hypertrophied  state  of  the  gland  arises  from  a previous  long 
continued  vascular  orgasm  or  congestion.  This  congested  state  of 


886 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  liver,  however,  is  always  preceded  and  accompanied  with  a 
greatly  deranged  condition  of  the  vascular  system  of  the  stomach, 
duodenum,  and  whole  intestinal  canal. 

In  this  disease  the  gall-hladder  usually  contains  thin  watery  hile  ; 
the  surface  is  more  or  less  tinged  yellow ; and  the  intestinal  dis- 
charges are' light  coloured.  A state  of  anaemia  with  ascites  follows. 

§ 9.  Atrophy. — The  term  Atrophy  of  the  Liver  has  been  ap- 
plied" to  more  than  one  state  of  that  organ ; certainly  to  two  at 
least.  The  first  is  a state  of  diminished  size,  with  contraction,  as  it 
were,  of  the  parenchyma  in  all  directions,  from  the  periphery  to  the 
sinus  of  the  vessels,  and  often  mostly  in  the  left  lohe,  sometimes 
with  persistence  of  its  parenchyma,  though  diminished  in  volume, 
sometimes  with  the  disappearance  of  the  red,  vascular,  or  acinoid 
tissue  of  the  gland,  and  the  substitution  of  a whitish  dense  tissue, 
which  is  manifestly  the  cellular  substance  of  the  gland.  The  second 
consists  in  diminished  volume  also  of  the  organ,  but  with  more  or 
less  induration,  and  a granular  or  tubercular  appearance  of  the 
liver;  in  short,  one  of  the  forms  of  kirrhosis.  Thirdly,  I have 
mentioned  an  instance  in  which  the  whole  gland,  but  especially  the 
right  lobe,  was  shrunk  and  contracted  to  about  one-third,  or  be- 
tween that  and  one-fourth  of  its  usual  size,  in  connection  with  an 
obstructed  state  of  the  portal  vein. 

It  is  not  easy  to  say,  in  the  present  state  of  our  knowledge,  to 
which  of  these  states  the  term  Atrophy  ought  to  he  confined.  One 
point  is  clear,  that  the  name  includes,  according  to  present  usage, 
several  morbid  states  of  the  liver,  which  are  in  all  probability  dif- 
ferent, and  proceed  from  different  causes.  It  is  clear  that  the  con- 
tracted state  of  the  liver  in  kirrhosis  ought  not  to  he  regarded  as  an 
instance  of  atrophy,  though  part  of  the  hepatic  tissue  in  that  dis- 
ease is  atrophied.  The  shrunk  and  contracted  state  of  the  gland 
in  that  affection  is  secondary  and  consecutive. 

That  there  are  cases  in  which  the  glandular  matter  of  the  liver 
is  diminished  or  atrophied  must  be  allowed,  from  such  cases  as  that 
given  by  Andral,  part  v.  livr.  ii.  chap.  iii.  section  ii.  obs.  12. 

§ 10.  Moschatismus  Jecoris In  certain  circumstances,  the 

liver,  when  divided,  presents  on  the  surface  of  the  sections  a mot- 
tled or  party-coloured  aspect  of  brown-coloured  spots,  set  in  a 
lighter  coloured  basis,  so  as  to  resemble  the  section  of  the  nutmeg. 
It  is  very  doubtful  whether  this  appearance  indicates  any  change  in 
structure.  The  dark-coloured  spots  appear  to  be  merely  sections 
of  granules  or  lobules  which  have  been  largely  injected  with  blood. 


GRANULATED  LIVER.  KIRRHOSIS. 


887 


while  the  light-coloured  basis  retains  its  normal  colour.  This  nut- 
meg aspect  of  the  liver-  is  connected  with  certain  states  of  the  vas- 
cular system  of  the  chest  and  abdomen,  in  which  some  impediment 
is  presented  to  the  circulation  of  the  blood.  Thus  it  takes  place 
in  various  affections  of  the  heart,  hypertrophy,  valvular  contraction, 
and  similar  affections,  in  which  the  blood  of  the  vena  cava  does  not 
easily  return  to  the  heart,  and  in  which  consequently  the  vena  cava 
hepatica  is  inordinately  distended.  It  may  also  take  place  in  con- 
sequence of  some  morbid  states  of  the  abdominal  circulation. 

§ 11.  Jecur  Granulatum. — Jecur  Tuberculatum, — Kir- 

RHOSis. It  has  been  already  mentioned,  that,  in  consequence  of  , 

inflammatory  congestion,  the  liver  is  liable  to  become  hardened, 
and  as  if  tuberculated  or  granulated.  It  may  be  that  this  is  the 
early  stage  of  the  state  which  is  to  be  described  under  this  head  by 
the  name  of  Granulated  Liver,  Tuberculated  Liver,  and  to  which 
Laennec  applied  the  epithet  of  Kirrhosis.  To  English  observers, 
it  was  known  partly  under  the  name  given  by  Baillie  of  Tubercu- 
lated liver,  and  more  frequently  in  its  exquisite  form  under  the 
name  of  hob-nailed  liver. 

Kirrhosis  appears  under  two  forms,  one  an  early,  another  a 
more  advanced  and  perfect. 

In  the  early  form  of  the  disease  the  substance  of  the  liver  is 
firm,  doughy,  yet  not  irregular.  The  surface  is  coloured  with 
patches  of  yellow,  variable  in  size.  The  whole  organ  is  in  gene- 
ral somewhat  enlarged,  and  usually  weighs  between  four  and  five 
pounds  or  more.  When  divided  it  appears  of  an  orange  red  co- 
lour, or  between  that  and  orange  brown  ; sometimes  with  patches 
of  this  colour  diffused  through  the  natural  colour  of  the  gland  ; 
and  when  a slice  is  immersed  in  water  it  soon  imparts  to  the  water 
a green  colour,  which  is  repeated  after  several  immersions.  Closely 
examined,  the  section  shows  innumerable  small  bodies  like  millet 
seed  or  grains  of  barley,  of  an  orange  colour,  dispersed  through  its 
substance.  Such  livers  are  vascular  in  the  red  granular  portion 
mostly. 

This  lesion  does  not  usually  prove  fatal  of  itself  at  this  stage ; 
but  persons  occasionally  die  with  the  liver  in  this  state,  from  dis- 
ease of  the  heart,  granular  disease  of  the  kidneys,  fever,  or  disease 
of  the  intestinal  canal. 

In  a more  advanced  stage  the  surface  of  the  liver  preseuts  at 
various  parts  small  irregular  shaped  elevations  like  the  heads  of 
vetches  or  peas,  separated  by  irregular  linear  furrows.  These  ele- 


888 


/ 

y 

GENEPwVL  AND  rAT>f6L0GlCAL  ANATOMY. 

.r' 

vations  may  not  extend  over  the  whole  liver,  but  occupy  at  first 
only  one  part,  viz.  gene/ally  the  convex  surface.  When  the  peri- 
toneum is  stripped,  M'hich  is  always  difficult  to  be  done,  it  is  ob- 
served that  the  .elevations  are  the  prominent  parts  of  roundish  or 
irregular-shapdd  bodies  about  the  size  of  tares  or  small  peas,  and 
some  as  large  as  peas.  The  colour  of  these  bodies  is  orange-brown 
or  wood-brown,  sometimes  a shade  lighter  than  the  colour  of  the 
sound  liver.  A section  of  such  presents  an  aggregation  of  bodies 
varying  in  size,  affecting  a roundish  irregular  outline,  united  or 
separated  by  whitish  fibrous  or  filamentous  lines.  The  liver  in 
these  parts  is  decidedly  firmer  and  harder  than  in  the  last  describ- 
ed case.  Other  parts  of  the  liver  are  firm,  doughy,  and  generally 
of  the  orange-yellow  or  orange-brown  tint. 

The  liver  in  this  state  may  not  be  larger  than  usual,  and  if  it  be, 
it  is  only  in  a slight  degree  larger. 

Sections  of  this  sort  of  liver,  when  macerated  in  water  repeatedly 
changed,  continue  long  to  impart  a green  colour  to  the  liquid. 

In  the  most  complete  form  of  the  disease  the  appearance  of  the 
liver  is  the  following.  The  liver  is  seldom  larger  than  natural. 
It  either  retains  its  normal  size,  or  it  is  smaller,  and  apparently 
shrunk  and  contracted.  The  whole  surface  of  the  liver  presents  the 
appearance  of  numerous  irregularly  round  bodies,  elevated  so  as 
to  give  the  organ  an  irregular  tuberculated  or  knotty  look.  These 
eminences  are  as  large  as  peas  or  small  beans,  a few  larger.  Their 
colour  externally  is  of  that  light  brown  usually  designated  wood- 
brown.  They  are  separated  by  well-marked  linear  furrows,  which 
seem  all  continuous,  so  that  the  surface  of  the  liver  presents  a re- 
semblance to  a shoe  covered  with  hobnails.  This  appearance  ex- 
tends over  the  whole  surface  of  the  liver  ; but  in  general  it  is  most 
distinct  and  conspicuous  on  the  convex  surface. 

The  shape  of  the  liver  is  at  the  same  time  in  general  more  or 
less  altered.  The  convex  surface  is  more  decidedly  convex ; the 
anterior  edge  is  obtuse,  thick,  and  as  it  were  bent  downwards ; all 
the  sharp  edges  are  rounded  or  obtuse : and  in  general,  by  the 
bending  downwards  of  the  right  and  left  margins,  and  the  anterior 
margin,  the  lower  surface  is  more  concave  than  in  the  natural 
state.  The  last  character,  however,  may  be  wanting ; and  the 
lower  surface  either  remaining  even,  though  irregularly  granulated, 
or  partaking  in  the  general  elevation,  the  whole  gland  appears 
thick,  but  rounded,  and  contracted  aj)parently  towards  the  sinus 
of  the  vessels. 


GRANULATED  LIVER.  KIRRHOSIS. 


889 


When  sections  of  a liver  in  this  state  are  made,  these  sections 
present  the  same  appearance  of  irregularly  rounded  bodies  aggre- 
gated together,  as  is  seen  at  the  surface.  The  colour  is  in  general 
more  of  the  orange-yellow  tint,  or  that  combined  with  wood-brown. 
These  bodies  are  united  by  a species  of  gray  filamentous  or  liga- 
mentous tissue ; and  both  structures  become  more  distinct  on  im- 
mersion in  water,  and  after  boiling. 

These  bodies,  though  affecting  the  globular  figure,  vary  much. 
Many  are  ovoidal  or  spheroidal ; many  are  irregularly  angular ; not  a 
few  are  elongated  with  rounded  or  angular  ends ; and  some  look  like 
the  small  stony  fragments  set  in  porphyry,  or  a small  grained  breccia. 

In  size  also  they  vary.  Some  are,  as  already  stated,  as  large  as 
good  sized  garden  peas ; and  this  volume  they  do  not  often  exceed. 
Others  are  smaller,  of  the  magnitude  of  dried  peas ; others,  again, 
like  tares  or  vetches ; and  some  not  larger  than  millet  seed.  All 
are  mixed  confusedly  together  without  any  order. 

The  peritoneum  may  be  stripped  from  these  bodies ; and  they 
then  present  the  appearance  of  an  aggregation  of  orange-brown  or 
wood-brown  looking  bodies,  all  closely  united  and  packed.  This 
close  conjunction  is  evidently  the  cause  of  their  variation  in  size 
and  shape ; for  it  is  manifest,  that  if  all  were  round,  they  could 
neither  touch  each  other  nor  be  of  the  same  size;  whereas,  beino- 
diflPerent  in  size,  the  small  bodies  are  interspersed  between  the  large 
ones ; and  the  shape  of  all  is  modified  by  tbe  contiguous  bodies. 

In  general,  I tbink  in  the  cases  examined  by  me,  the  bodies  at 
tbe  surface  are  both  larger  and  more  regularly  rounded  than  those 
in  the  substance  of  the  liver. 

I have  several  times  macerated  sections  of  kirrhotic  liver;  and 
I always  found  that  they  required  a long  time,  months  at  least,  to 
part  even  with  a portion  of  their  greenish  colouring  matter.  In 
several  cases  I kept  slices  of  granulated  liver,  for  spaces  of  from  20 
to  24  months,  in  water  periodically  changed,  before  attempting  to 
put  them  in  spirits ; and  even  then,  in  the  course  of  a few  weeks, 
the  spirits  were  completely  coloured  green,  and  required  to  be 
changed ; and  the  spirit  in  which  the  section  so  prepared  was  im- 
mersed, was  again  tinged  green.  This  fact  shows  the  tenacity  with 
which  the  colouring  matter  adheres  to  these  granules. 

This  green  colouring  matter  is  precipitated  by  the  addition  of 
hydrochloric  acid.  A fatty  matter  is  taken  up  by  ether. 

From  the  prominent  characters  now  described,  Morgagni  applies 
to  this  state  of  the  change  the  name  of  jecur  granulatum ; Baillie 


890 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


terms  it  tuberculated  liver ; many  physicians,  both  in  this  country 
and  abroad,  term  it  granulated  liver ; and  Laennec  applied  to  it 
the  name  of  kirrhosis,  or  yellow  degeneration  of  the  liver,  from  the 
colour  which  the  liver  so  changed  often  presents. 

Besides  the  forms  now  described,  the  disease  in  certain  instances 
appears  in  the  form  of  yellow  matter  dispersed  through  the  sub- 
stance of  the  liver  like  peas ; or  presents  an  appearance  similar  to 
the  vitellarium  of  the  common  fowl. 

In  some  instances  small  empty  cavities  are  found  in  the  interior 
of  the  granulated  liver ; and  in  others  are  small  cavities  containing 
a greenish  jelly-like  liquid  of  little  consistence.  This,  which 
appears  to  have  been  observed  by  Portal,  is  made  the  ground  of 
another  stage  of  the  disease  more  advanced  than  the  one  last  men- 
tioned. The  distinction  I think  entirely  useless,  as  the  state  men- 
tioned is  found,  though  not  very  often,  in  the  state  already  describ- 
ed as  the  third  stage. 

Laennec,  who  considered  this  yellow  matter  a new  formation, 
characteristic  of  the  lesion,  admitted  three  forms  of  hirrhosis ; one 
in  masses,  a second  in  patches,  and  a third  in  cysts.  This  idea  of 
the  separate  new  morbid  formation  has  not  been  generally  recog- 
nized ; and  it  is  probable  that  these  distinctions,  which  apply  rather 
to  the  external  form  than  the  essential  character  of  the  lesion,  are 
fanciful. 

A liver  in  the  exquisite  and  perfect  form  of  granulation  presents 
in  its  snbstance  appearances  so  characteristic,  that,  though  not 
easily  described,  they  have  attracted  general  attention.  The 
orange-coloured  matter  has  been  sometimes  described  as  like  sole- 
leather,  when  attempted  to  be  cut  by  the  knife ; and  in  other  in- 
stances the  section  has  been  compared  to  impure  bees  wax.  Both 
of  these  statements  are  either  inaccurate  or  exaggerations.  The' 
granulated  liver  is  certainly  not  so  tough  and  inflexible  as  sole  lea-' 
ther ; neither  does  it  present  the  hard  yet  friable  property  of  yel- 
low bees  wax.  It  resembles  a solid,  close,  dense,  fleshy  mass,  con- 
sisting apparently  of  numerous  small  bodies  irregularly  aggregated 
together,  which,  when  closely  inspected,  are  of  an  orange  or  orange- 
brown  colour. 

This  disease  tends  certainly  and  invariably  to  the  formation  of 
incurable  abdominal  dropsy.  At  first  the  liver  is  larger  than  usual ; 
but  afterwards  it  returns  to  its  normal  size,  though  not  to  the 
normal  shape,  or  it  becomes  smaller  and  shrunk,  as  already  de- 


GRANULATED  LIVER.  KIRRHOSIS. 


891 


scribed.  I have  seen  three  persons  among  about  32  cases  die  with 
intestinal  hemorrhage.  Becquerel  observed  this  five  times  in  42 
cases. 

It  is  not  uncommon  for  the  granulated  liver  to  he  affected  with 
superficial  or  peritoneal  inflammation,  and  thus  to  contract  adhe- 
sions to  adjoining  parts.  In  two  cases  I found  the  convex  surface 
adhering  extensively  by  false  membrane  to  the  diaphragm.  This 
might  have  taken  place  previous  to  the  granular  transformation. 
I have  seen  the  liver  also  adhering  in  this  state  to  the  stomach,  and 
to  the  duodenum. 

Sometimes  the  gall-hladder  is  found  thickened,  and  adhering 
preternaturally  to  adjoining  parts. 

The  capsule  of  Glisson  is  usually  thickened,  and  appears  to  have 
been  the  seat  of  chronic  inflammation. 

The  state  of  the  bile  varies.  In  some  cases  it  appears  not  per- 
ceptibly changed.  In  others  it  is  dark-coloured,  viscid,  ropy.  In 
a few  it  is  liquid,  light-coloured,  and  manifestly  serous.  In  these 
states  there  appears  to  be  nothing  regular. 

Attenda^jt  lesions. — Kirrhosis  may  take  place  alone,  that  is, 
without  lesion  of  other  organs,  or  at  most  with  a morhid  state  of 
the  alimentary  canal  and  its  mucous  membrane.  But  it  is  more 
common  for  it  to  be  conjoined  with  lesions  of  other  organs.  The 
most  common  morbid  accompaniment  in  this  country  is  granular 
disease  of  the  kidney  ; and  I have  seen  a great  number  of  instances 
in  which  the  latter  lesion  was  conjoined  with  kirrhosis  either  in  the 
early  or  in  the  advanced  stage.  Becquerel,  who  has  studied  the 
lesion  particularly  in  this  view,  found  among  42  cases  only  7 which 
could  be  said  to  be  simple  or  unconnected  with  lesion  of  other  or- 
gans. Among  these  were  19  in  which  the  granulated  state  of  the 
liver  was  complicated  or  associated  with  the  granular  state  of  the 
kidney ; in  2 1 kirrhosis  was  complicated  with  disease  of  the  heart 
in  different  stages,  and  in  two  with  pericarditis.  The  most  usual 
cardiac  lesion  was  hypertrophy  of  the  left  chambers  ; hypertrophy 
of  the  right  chambers ; and  changes  in  the  valves  of  the  left  cham- 
bers in  the  order  now  observed.  In  9 cases  he  found  pulmonary 
emphysema ; and  in  one  case  pulmonary  tubercles. 

In  this  country  the  disease  is  not  so  frequently  associated  with 
well-marked  disease  of  the  heart ; but  in  almost  all  the  cases  which 
I have  examined,  there  were  traces  of  chronic  bronchitis  and  em- 
physema. 


802 


GENERAL  AND  PATHOLOGICAL  ANATOMY, 


Though  abdominal  dropsy  is  the  constant  and  invariable  effect 
of  this  lesion,  so  much  so,  that  in  every  case  of  abdominal  dropsy 
which  is  unattended  by  manifest  enlargement  of  the  liver,  it  may 
be  inferred  that  this  gland  is  in  the  granulated  state,  yet  the  dis- 
ease may  be  followed  or  associated  with  other  lesions  which  precede 
the  fatal  event.  Thus  it  may  cause  chronic  peritonitis  ; pleurisy, 
especially  the  chronic  form  ; less  frequently  pericardial  inflamma- 
tion ; pneumonia  occasionally  ; pulmonary  apoplexy  ; and  if  not, 
expectoration  tinged  with  blood. 

From  the  observations  of  Dr  Eichholtz  of  Konigsberg,  I infer 
that  the  conjunction  of  granulated  liver  with  granular  kidney  is 
also  frequent  in  Germany.* 

The  nature  and  cause  of  this  degeneration  has  given  rise  to 
much  inquiry  and  considerable  difference  of  opinion.  We  have 
seen  that  Laennec  imagined  that  it  consisted  in  the  formation  of  a 


new  morbid  product,  which  was  infiltrated  into  the  substance  of  the 
liver,  which  was  liable  to  be  formed  in  the  same  manner  in  the  pa- 
renchyma of  other  organs,  and  which  appearing  at  first  in  an  in- 
cipient or  nascent  state,  proceeded  eventually  to  softening.  It  was 
further  the  idea  of  Laennec,  that  as  the  kirrhotic  bodies  were 
developed,  the  substance  of  the  liver  disappeared  and  was  ab- 
sorbed. 

The  correctness  of  this  idea  was  first  questioned  by  M.  Boulland, 
who  denies  the  fact  of  a new'  formation,  and  maintains  that  hirrhosis 
consists  in  what  he  calls  a dissociation  of  the  elements  of  the  liver, 
viz.  the  glandular  yellow  portion  and  the  red  vascular  portion.  In 
the  early  stage,  he  conceives  that  the  vascular  network  is  enlarged 
and  much  loaded  with  blood.  In  the  second  stage,  this  vascular 
netw'ork,  which  is  interposed  between  the  granules  of  the  yellow' 
portion,  becomes  impermeable,  but  large  ; it  assumes  a colour  va^ 
rying  from  gray  rose  to  pale  green,  and  allows  turbid  serum  to 
escape.  This  idea  implies  that  the  granulated  state  of  the  liver  is 
owing  to  congestion.! 

Andral  ascribes  kirrhosis  to  hypertrophy  of  the  yellow  or  gra- 
nular matter  of  the  liver,  while  the  red  or  vascular  matter  remains 
either  the  same,  or  may  be  changed  in  colour  to  an  olive-green, 


* Ueber  die  Granulirte  Leber  und  Niere,  und  ihr  Verhaltnis  zur  Tuberciildsen 
und  Krebsigen  Dyscrasie.  Von  Dr  H,  Eichholtz  zu  Konigsberg.  Muller’s  Archiv 
fur  Anatomic  und  Physiologie.  Jahrgang,  1845.  Berlin.  Seite  320. 

-f-  Memoires  de  la  Societe  Medicale  d’Bmulation.  Tome  ix. 


NATURE  OF  KIRRHOSIS, 


893 


witli  increase  or  duninution  in  its  volume ; the  latter  being  the 
cause  of  the  shrivelling.  * * * § 

Cruveilhier,  as  well  as  Andral,  denies  the  formation  of  a new 
substance  ; and  considering  the  appearance  and  relation  of  the  mi- 
nute bodies  constituting  this  change,  he  infers  that  they  are  part  of 
the  acini  or  glandular  granules  of  the  liver  in  a state  of  hypertrophy, 
while,  in  consequence  of  these  hypertrophied  granules,  the  others 
are  atrophied  or  wasted,  f 

In  1837,  Dr  Carsewell  brought  forward,  on  the  nature  and  for- 
mation of  this  disease,  an  hypothesis  which  has  had  in  several  points 
several  followers.  Rejecting  the  idea  of  Laennec,  that  kirrliosis 
depends  on  the  formation  of  a new  tissue.  Dr  Carsewell  regards 
the  change  as  consisting  in  atrophy  of  the  lobular,  that  is  the  glan- 
dular structure  of  the  organ,  produced  by  the  presence  of  a con- 
tractile fibrous  tissue  formed  in  the  capsule  of  Glisson.  | This 
idea  has  been  more  or  less  decidedly  adopted  by  Mr  O’Ferrall, 
Mr  R.  W.  Smyth,§  and  some  others  : while  part  of  the  hypothesis, 
that  relating  to  the  induration  of  the  substance  of  the  capsule  of 
Glisson,  corresponds  with  an  hypothesis  presently  to  be  mentioned. 

In  1839,  Dr  Hallmann  of  Berlin  announced  formally  in  his 
dissertation  an  hypothesis  which  had  been  in  various  modes  and 
quarters  occasionally  produced.  This  is,  1st,  that  in  kirrhosis, 
hypertrophy  of  the  cellular  or  ligamentous  tissue  of  the  liver  takes 

* Clinique  Medicale,  Partie  Vieme,  Liv.  Ilieme,  Section  I.  Chapitre  III.  Paris, 
1834. 

The  ideas  of  M.  Andral  regarding  the  granular  liver  are  founded  on  his  notions  of 
its  natural  anatomical  structure.  This  is  perfectly  correct  were  these  notions  well 
founded.  But  either  these  are  not  accurate,  or  they  do  not  accord  with  the  idea  of  the 
majority  of  anatomical  observers.  He  states  that  in  the  liver  two  substances  exist  na- 
turally, so  arranged  as  to  represent  the  form  of  a sponge.  One  more  or  less  white  re- 
])i-esents  the  solid  part  of  the  sponge,  contains  large  vessels  which  traverse  without  ra- 
mifying in  it,  and  consequently  contains  little  blood.  The  other  is  a red  substance, 
extremely  vascular,  in  appearance  cavernous,  and  is  deposited  in  the  areola  of  this 
white  substance. 

The  white  substance  of  which  M.  Andral  here  speaks  appears  to  be  the  interlobular 
and  intergranular  cellular  tissue.  The  red  substance  is  indeed  vascular,  and  is  con- 
tained in  its  areola; ; but  besides  this,  there  is  an  orange  or  yellow  substance,  which 
is  the  granular  or  acinoid,  and  which  consists  of  the  ends  of  gall-ducts  throughout  the 
whole  gland. 

•f  Anatomie  Pathologique,  LirTaison  xii.  Paris,  1837. 

i Illustrations  of  the  Elementary  Forms  of  Disease.  By  Robert  Carsewell,  M.  D. 
London.  Folio.  1838.  Atrophy  2,  Plate  ii. 

§ Dublin  Journal,  Volume  xxv.  p.  S21-.524.  Dublin,  1844. 


894 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


place ; 2d,  that  in  this  hypertrophy  of  the  hepatic  cellular  tissue 
consists  the  essential  character  of  the  pathological  change  called 
kirrhosis.  These  propositions  he  maintains  that  he  proved,  by 
showing  microscopically  the  increased  quantity  of  cellular  tissue 
which  the  kirrhotic  liver  presents  ; and  chemically,  by  the  quantity 
of  gelatin  which  he  obtained  by  boiling  from  the  kirrhotic  liver, 
and  which  is  to  that  of  the  sound  liver,  by  taking  like  weights,  as 
five  to  one.  He  obtained  from  three  ounces  of  kirrhotic  liver  66 
grains  of  dry  gelatin,  and  from  the  same  quantity  of  healthy  liver 
only  13  grains. 

Dr  Hallmann  further  observes  that  the  yellow  bodies  (granula- 
tions, kirrhotic  nodules)  consist  partly  of  cells  filled  with  more  or 
fewer  fat  globules,  and  thereby  often  expanded  beyond  their 
proper  volume,  and  partly  of  large  free  fat  globules.  Their  me- 
dium diameter  is  about  106  thousandth  parts  of  one  Paris  inch. 
The  fat  may  be  forced  from  them  by  pressure ; but  seldom  do 
they  show  a distinct  nucleus.  By  maceration  in  solution  of  caustic 
alkali,  the  fat  is  dissolved.  The  accumulation  of  fat  within  and 
without  the  cells  is  not  peculiar  to  the  kirrhotic  liver,  but  is 
observed  in  the  drunkard’s  liver,  and  occasionally  in  livers  reputed 
sound.  The  basement  tissue  which  surrounds  the  yellow  granules, 
consists  partly  of  closely  compressed  cells,  partly  of  thin  compact 
fibres,  which  are  much  more  abundant  here  than  in  the  sound 
liver.  From  the  several  facts  now  specified,  he  concludes  that  the 
toughness  and  hardness  of  the  granular  liver  proceeds  from  an 
augmentation  of  the  cellular  tissue  of  the  capsule  of  Glisson, 
caused  by  chronic  inflammation.* 

Imperfect  as  this  hypothesis  is,  it  is  supported  by  Muller  of 
Berlin,  who  closes  some  interesting  observations  on  the  structure 
of  the  liver  with  the  following  remarks.  “ According  to  my 
observations,  kirrhosis  consists  principally  in  hypertrophy  of  the 
interlobular  ligamentous  tissue',  at  the  expense  of  the  glandular 
or  lobular  substance  of  the  liver,  by  which  individual  lobules  and 
separate  masses  of  lobules  are  removed  and  as  if  extruded  from 
the  others  in  a striking  manner.  In  a remarkable  specimen  of 
kirrhosis  in  the  Anatomical  Museum,  this  is  so  palpable,  that  it 
may  be  seen  in  the  section  of  the  liver  by  the  naked  eye.  I con- 

* Bemerkung  uber  die  Lebercirrhose  von  Dr  E.  Hallmann.  A Berlin.  Muller’s 
Archiv  fur  Anatomie,  Physiologie,  un  Wissenchaftliche  Medicin.  Jahrgang.  1843. 
Berlin.  475. 


4 


NATURE  OF  KIRRHOSIS. 


895 


jecture  that  kirrhosis  depends  on  local  dissimilar  hypertrophy  of 
the  interlobular  or  interacinous  connecting  tissue.”* 

I mention  the  hypothesis  of  Muller  in  this  place,  because,  though 
not  published  till  1843,  it  appears  that  it  had  been  taught  by  the 
author  previously. 

Meanwhile  Becquerel  adduced  in  April  1840,  a view  which  has 
always  appeared  to  me  more  consonant  with  the  facts,  and  which, 
in  truth,  I had  myself  maintained  before  the  appearance  of  the 
essay  of  that  author. 

Becquerel  maintains  that  in  kirrhosis  the  only  tissue  primarily 
affected  is  the  yellow  substance  of  the  liver ; that  this  yellow  sub- 
stance, which  he  should  have  called  the  glandular  tissue,  is  infil- 
trated with  plastic  or  albumino-fibrous  yellow  matter,  quite  similar 
to  the  false  membranes  of  the  serous  tissues  ; that  from  this  results 
hypertrophy  of  the  yellow  substance  of  the  liver  ; and  that  from 
this  hypertrophy  arises  at  first  compression,  and  subsequently 
atrophy  of  the  greatest  part  of  the  red  or  interlobular  substance. 
He  further  thinks,  that,  though  it  is  difficult  to  speak  positively  on 
the  cause  of  the  infiltration  of  this  yellow  matter  in  the  glandular 
. tissue  of  the  liver,  yet  most  probably  it  is  the  result  of  repeated 
vascular  congestions.! 

It  is  impossible  to  doubt  that  this  makes  the  nearest  approach  to 
the  correct  explanation  of  the  phenomena ; and  as  it  is  that  which 
I have  for  several  years  been  in  the  habit  of  teaching  in  demon- 
strations and  lectures,!  I do  not  hesitate  to  add  a few  words  in 
further  explanation. 

It  has  been  formerly  shown,  that  the  hepatic  substance  consists 
of  three  separate  elementary  tissues ; a red,  or  vascular  ; an  orange 
or  glandular  ; and  a gray  or  filamentous. 

The  vascular  tissue  consists  of  the  capillary  or  minute  vessels  of 
the  hepatic  artery,  portal  vein,  and  the  origins  of  the  hepatic 
veins.  This  constitutes,  in  the  healthy  liver,  and  especially  in 
early  life,  the  largest  proportion  of  the  gland. 

Disseminated  through  this  capillary  network,  which  forms  the 

* Uber  den  Ban  der  Leber.  Anmerkung  zui  Vorstehenden  Abhandlung  von  Heraus- 
geber.  Archiv  fur  Anatomie.  Jahrgang.  1843.  Berlin.  P.  343. 

-|-  B,echerches  Anatomico-Pathologiques  sur  la  Cirrhose  du  Foie.  Par  Alfred 
Becquerel.  Archives  Generales  de  Medecine.  Tomelii.  Aral  1840.  P.  398  et  407. 

J Report  on  the  Cases  treated  during  the  Course  of  Clinical  Lectures  delivered  at 
the  Royal  Infirmary  in  Session  1832-1833.  By  David  Craigie,  M.  D.  F.  R.  S.  E.  &c. 
Edinburgh  Medical  and  Surgical  Journal,  Voh  xli.  p.  112 — 118.  Edinburgh,  1834. 


89(5 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


basis  of  the  gland,  is  the  second  tissue,  generally  of  an  orange  co- 
lour, in  the  form  of  minute  granules  or  atoms,  which  consist  of  the 
terminal  ends  of  biliary  ducts,  or  what  have  been  named  acini.  It 
is  not  easy  to  say  whether  single  acini,  or  groups  and  clusters  of 
acini.,  thus  form  these  orange-coloured  interposed  granules.  The 
question  is  of  little  moment.  The  main  fact,  which  it  is  important 
to  know  and  remember,  is  that  this  orange-coloured  matter  is  sur- 
rounded by  or  enclosed  in  the  vascular  network,  as  it  were ; that 
it  is  the  proper ’granular  or  secreting  part  of  the  liver;  and  that  it 
is  formed  by  the  superior  or  terminal  ends  of  the  biliary  pori.  This 
matter  is  much  less  abundant,  and  occupies  much  less  space  of  the 
gland,  though  disseminated  through  its  entire  substance. 

The  third  substance  is  white  or  gray,  and  consists  of  filamentous 
tissue,  which  encloses  the  vessels  on  the  one  hand,  and  the  bile- 
ducts  on  the  other,  throughout  the  whole  gland,  connecting  all  to- 
gether in  one  body.  This  is  supposed  by  some  to  be  a prolonga- 
tion or  process  from  the  capsule  of  Glisson,  and  thence  to  be  con- 
tinued along  the  vessels  through  the  parenchyma  of  the  gland. 
There  is  no  doubt  that  this  hepatic  cellular  tissue  is  connected  with 
the  capsule  of  Glisson,  and  may  be  traced  from  it;  but  it  is  of  little 
moment  whether  we  admit  that  it  is  a prolongation  of  that  capsule 
or  not.  This  third  substance  is  easily  known  by  the  gray  or  whit- 
ish intersecting  lines  which  it  forms  all  through  the  liver. 

Now,  of  the  three  elementary  tissues  thus  constituting  the  liver, 
it  is  the  second,  viz.  the  orange-coloured  granular  substance,  which 
is  primarily  affected  in  kirrhosis.  This  affection  consists  in  en- 
largement and  induration  of  the  granular  bodies,  until  they  attain 
the  size,  shape,  and  general  appearance  of  kirrhotic  granulations 
or  nodules ; in  short,  are  hypertrophied.  That  this  is  the  fact,  I 
conceive  is  proved,  first  by  their  appearance  in  complete  states  of 
kirrhosis ; and,  secondly,  by  the  other  phenomena  which  have  been 
mentioned  in  the  general  description.  The  appearance  of  granu- 
lations of  different  sizes,  from  pin-heads  up  to  the  volume  of  peas 
or  hazel-nuts,  can  be  produced  only  by  the  growth  and  enlarge- 
ment of  the  original  granular  bodies  of  the  liver.  These  bodies 
are  of  different  sizes,  because  necessarily  the  morbid  process  com- 
mences in  some  granules,  before  others  are  affected ; and  those  in 
which  it  first  commences,  must  be,  and  are  largest.  Secondly,  these 
bodies  contain  the  colouring  matter  and  fatty  matter  of  the  bile, 
indeed  the  parts  that  cannot  escape  by  filtration ; and  this  circum- 


NATURE  OF  KIRRHOSIS. 


897 


stance  alone  is  sufficient  to  show  that  the  glandular  or  granular 
portion  of  the  liver  is  the  part  affected  by  kirrhosis. 

It  must  not  be  forgotten  therefore,  that  though  the  hypertrophy 
affects  the  whole  of  the  granular  or  orange-matter  of  the  liver,  it 
affects  it  unequally ; some  being  more,  others  less  affected. 

As  to  the  exact  change  induced  in  these  bodies,  it  is  most  pro- 
bable that  the  bile-tubes  are  first  contracted,  and  eventually  oblite- 
rated by  adhesive  inflammation  ; for  little  genuine  bile  ever  reaches 
the  hepatic  ducts,  in  the  established  form  of  the  disease ; and  in  all 
the  largest  tubercles,  it  is  reasonable  to  tbink  that  the  ducts  are 
either  much  contracted  or  completely  closed. 

The  red  or  vascular  portion  of  the  gland  is,  at  the  same  time, 
ati’ophied ; and  its  waste  or  diminution  appears  in  some  instances 
to  proceed  to  a very  great  extreme.  Baillie  observed  that  the  gra- 
nulated liver  contains  little  blood ; a fact  which  is  confirmed  by 
daily  observation.  The  granulated  liver  cannot  be  injected  to  any 
extent.  The  small  vessels  are  obliterated  evidently  by  the  pressure 
of  the  granulated  bodies  on  them. 

It  is,  therefore,  not  hypertrophy  of  one  set  of  granules,  and 
atrophy  of  another,  as  imagined  by  Cruveilhier,  that  is  the  essential 
circumstance  in  kirrhosis,  but  hypertrophy  of  the  whole  of  the 
orange-coloured  tissue,  and  atrophy  of  the  vascular  portion. 

The  reason  why  it  has  appeared  to  many  that  the  granular  part 
could  not  be  hypertrophied,  when  the  whole  liver  was  actually 
smaller,  is  the  circumstance,  that  they  overlook  the  anatomical  fact, 
that,  in  the  sound  state,  the  granular  portion  of  the  li\  er  makes  but 
a small  proportion  of  the  gland,  while  the  vascular  portion  forms 
the  most  considerable ; whereas,  when  hypertrophied  as  in  kirrhosis, 
the  granular  portion  constitutes  almost  the  whole. 

Along  with  these  changes,  the  interlobular,  cellular,  or  filamen- 
tous tissue  is  hardened,  apparently  by  inflammatory  adhesion.  This 
has  been  assumed  to  be  the  cause  of  the  other  changes ; but  it  is 
manifestly  merely  a concomitant  effect.  It  is  always  most  remark- 
able in  the  concave  portion  of  the  liver,  and  much  less  so  in  the 
convex.  Conversely  the  granular  degeneration  is  usually  most 
complete  and  furthest  advanced  at  the  convex  surface  of  the  liver, 
and  least  so  in  the  neighbourhood  of  the  capsule  of  Glisson  and 
the  sinus. 

The  remote  causes  of  kirrhosis  are  not  very  accurately  known  ; 
and  all  the  information  which  has  been  given  on  this  subject  is  ra- 
ther conjectural  than  positive.  During  the  years  1817  and  1818, 

3 n 


898 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


when  my  attention  was  first  directed  to  the  granular  or  tubercu- 
lated  liver,  I inspected  a considerable  number  of  cases,  several  of 
the  subjects  of  which  I had  opportunities  of  seeing  during  life.  A 
good  proportion  of  these  cases,  at  least  two-thirds,  occurred  in  per- 
sons who  had  been  as  soldiers  in  the  expedition  to  Walcheren; 
and  after  becoming  acquainted  with  this  fact,  I inferred  that  it  is 
one  of  the  states  of  liver  disease  induced  by  miasmatic  poison. 
Subsequent  observation,  however,  satisfied  me  that  this  conclusion 
is  too  limited.  I afterwards  met  with  instances  of  granular  liver 
in  all  its  stages  in  persons  who  had  not  been  in  aguish  districts. 
Between  1831  and  1845,  I saw  cases  of  the  disease  arising  appa- 
rently under  every  variety  of  different  circumstances  ; residence  in 
cold  countries,  residence  in  hot  and  tropical  climates,  in  persons 
who  had  never  been  out  of  Great  Britain.  At  the  same  time, 
while  a considerable  proportion  of  cases  was  found  in  the  persons 
of  Irish  who  had  migrated  to  Scotland,  it  was  not  always  ascer- 
tained that  these  persons  had  been  in  the  bog  districts  of  Ireland. 
The  cause  which  seems  most  usually  and  generally  to  be  followed 
by  the  development  of  this  degeneration  is  the  habitual  use  of  spi- 
rits ; and  to  this  cause,  both  in  London  and  in  Edinburgh,  great 
numbers  of  granulated  liver  may  be  traced. 

While  the  influence  of  this  agent  is  admitted  by  Becquerel,  he 
adds  various  other  circumstances  ; gloomy  and  distressing  mental 
emotions,  bad  and  innutritions  food,  and  residence  in  damp  situa- 
tions and  dwellings. 

The  influence  of  sex  and  age  it  is  not  easy  to  determine.  Among 
18  cases  of  simple  kirrhosis,  Becquerel  found  12  to  be  in  males 
and  6 in  females.  Among  45  cases  of  complicated  kirrhosis,  28 
were  in  males  and  17  in  females.  Among  the  cases  seen  by  my- 
self in  1817  and  1818,  all  occurred  in  males.  Among  those  seen 
afterwards,  3 among  females  were  observed  to  5 among  males. 

Among  1 8 cases  noted  by  Becquerel,  7 took  place  between  the 
ages  of  30  and  40,  and  5 between  50  and  60.  Among  those  in 
which  the  age  was  noted  by  myself,  two  cases  took  place  in  young 
females  of  20,  two  in  females  between  35  and  40,  one  in  a man  of 
35,  and  other  three  in  men  between  35  and  50.  The  disease, 
therefore,  seems  to  be  most  prevalent  between  30  and  50,  or  30 
and  45. 

As  to  exciting  pathological  causes,  Becquerel  maintains  that  dis- 
ease of  the  heart  is  a frequent  antecedent,  and  must  be  considered 
as  a cause  of  eranular  deareneration  of  the  liver.  This  inference  he 


NATURE  OF  KIRRHOSIS. 


899 


adopts,  because  he  found  21  instances  of  kirrhosis  among  a series 
of  55  instances  of  disease  of  the  heart.  Granulated  liver  is  doubt- 
less found  often  associated  with  disease  of  the  heart ; but  often  also 
the  latter  disease  is  without  the  former,  while  the  nutmeg  state  of 
the  liver  is  present  Again,  it  is  not  doubtful  that  kirrhosis  is  often 
associated  with  vascular  congestion  and  irritation  of  the  stomach, 
duodenum,  and  jejunum  ; and  it  is  almost  certain,  that  the  mode 
in  which  the  habitual  use  of  spirituous  drinks  operates  in  causing 
kirrhosis,  is  partly  owing  to  this  irritation,  partly  to  absorption  into 
the  abdominal  venous  system. 

When  kirrhosis  is  associated  with  renal  granulation,  it  seems  less 
reasonable  to  ascribe  the  one  of  these  affections  to  the  presence  of 
the  other,  than  to  ascribe  both  to  the  same  cause.  They  also  ap- 
pear to  be  similar  forms  of  degeneration  of  the  glandular  tissue  in 
different  glands. 

It  is  not  doubtful  that  kirrhosis  is  quite  adequate  of  itself  to  cause 
death.  It  must  nevertheless  be  allowed,  that  it  is  often  found 
associated  with  other  lesions  which  are  usually  fatal ; for  instance, 
chronic  bronchitis,  hypertrophy  and  valvular  disease  of  the  heart, 
and  disease  of  the  kidney,  occasionally  continued  fever,  and,  in  a 
few  instances,  pulmonary  consumption.  When  fatal  without  these 
diseases,  it  is  invariably  found  terminating  in  incurable  ascites. 

It  could  not  be  expected  that  so  great  a change  in  the  structure 
of  the  liver  should  be  without  effects  on  the  health  and  general  sys- 
tem. Yet,  in  the  early  stage,  it  rarely  produces  conspicuous  symp- 
toms. Kirrhosis  is,  indeed,  an  insidious  disease,  causing  little  dis- 
turbance until  the  liver  is  altogether  changed  in  structure.  The 
liver  is  seldom  so  much  enlarged  in  the  early  stage  as  to  give  rise 
to  manifest  and  palpable  swelling ; and  there  is  at  this  time  also 
little  or  no  serous  fluid  within  the  abdomen.  Pain  is  not  felt,  at 
least  not  mentioned  by  patients  ; and  all  that  can  be  observed  is  a 
feeble  and  irregular  state  of  the  digestive  function,  denoted  by  want 
of  appetite,  thirst,  constipation,  a sense  of  heat  at  times  in  the  palms 
of  the  hands,  and  general  feebleness  and  languor.  Nutrition  is 
manifestly  impaired.  As  the  disease  advances  the  liver  is  enlarged, 
and  continues  so  for  some  time.  Then  it  is  diminished ; and  no 
tumour  may  be  felt  in  the  hypochondriac  region. 

Bile  is  evidently  not  secreted ; for  the  motions  are  usually  paler 
than  in  their  normal  state.  Yet  jaundice  is  an  occurrence  so  rare 
that  I have  never  seen  it  in  a distinct  and  well-marked  form. 
All  that  is  observed  is  a peculiar  dingy  brownish'  or  sallow 


900 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


colour  of  the  face  and  skin  generally,  wliieh  is  so  characte- 
ristic, that,  though  not  strongly  marked,  if  once  or  twice  seen,  it 
can  rarely  be  mistaken.  It  has  often  appeared  to  me  also,  that  the 
perspiration  of  patients  with  this  disease  has  a peculiar  odour.  All 
perspire  during  the  night  or  towards  morning  with  a peculiar 
unctuous  discharge.  The  urine  contains  no  bile  ; but  it  is  scanty, 
deep-coloured,  contains  a large  proportion  of  urea,  and  deposits  a 
sediment  of  urate  of  ammonia. 

At  length  fluid  is  accumulated  within  the  abdomen ; and  the 
strength  is  still  more  completely  impaired. 

Death  occasionally  takes  place  by  coma,  the  bile  not  being  elimi- 
nated, and  acting  as  a poison. 

Kirrhosis  may  be  complicated  with  abscess  of  the  liver.* 

§ 12.  Steatosis.  Pimelosis.  Fatty  Degeneration. — Though 
the  liver  even  in  the  human  body,  in  its  healthy  state,  contains  in 
its  cells  some  oily  matter,  which  may  be  obtained  from  it  by  various 
means,  yet  in  ordinary  circumstances  this  is  so  small,  that  it  has 
been  generally  overlooked. 

On  the  other  hand  this  element,  if  element  it  be,  is  liable  to  be 
augmented  to  so  great  an  extent,  that  it  is  infiltrated  interstitially 
into  the  acini  and  around  them,  and  constitutes  a peculiar  morbid 
state,  to  which  the  name  of  fatty  liver  has  been  applied. 

A liver  in  this  state  is  very  generally  larger  and  heavier  than  in 
the  healthy  state,  sometimes  amounting  to  double  the  weight,  or 
7,  8,  or  9 pounds.  It  may,  nevertheless,  he  not  above  4^  or  5 
pounds.  When  large,  it  may  be  felt  during  life  in  the  form  of  a 
large,  prominent,  but  smooth  tumour,  under  the  margin  of  the  right 
hypochondre,  which  it  raises,  filling  the  epigastric  region,  which  is 
rendered  prominent  and  full,  and  extending  somewhat  into  the  left 
hypochondriac  region.  All  over  this  space  the  tumour  emits  a 
dull  sound  on  percussion,  but  feels  not  unusually  hard. 

The  fatty  liver  generally  covers  the  stomach  and  transverse  arch 
of  the  colon,  and  descending  about  three  inches  below  the  margin 
of  the  hypochondre,  and  spreading  beyond  the  median  line,  appears 
prominent  and  conspicuous,  concealing  all  the  viscera  in  the  epi- 
gastric region.  The  enlargement  usually  affects  the  whole  gland. 

A liver  in  this  state,  when  first  exposed,  is  of  a pale  orange,  or 
reddish  yellow  colour,  or  yellowish  marbled,  some  parts  being 
deeper  and  others  lighter  coloured.  These  colours  are  dispersed 
in  patches,  various  in  size,  over  the  liver.  The  surface  is  smooth, 

* Case  by  Dr  H.  Beer  in  Oesterreichische  Mediz.  Wochenschrift.  1843.  N.  22. 


FATTY  DEGENEEATION  OF  THE  LIVER. 


901 


and  something  doughy,  or  compressible-inelastic  to  feeling;  less 
solid  and  dense  than  the  natural  liver.  When  divided,  the  sec- 
tions are  yellowish  red,  or  with  the  tint  of  the  fat  of  old  oxen 
mixed  with  the  red  colour  of  the  liver.  lu  advanced  stages,  the 
colour  is  _still  more  highly  yellow,  approaching  to  gold  yellow. 
The  substance  is  soft,  doughy,  and  sometimes  lacerable.  These 
sections  leave  on  the  knife  a distinct  dirty,  greasy  mark  ; and  even 
paper  applied  over  the  cut  surface  receives  an  oily  stain,  while 
fresh  particles  of  dirty  grease  ooze  from  the  surface. 

This  fatty  matter  is  deposited  or  infiltrated  partly  within  the 
acini  and  granules,  partly  at  their  exterior ; while  the  acini  in  the 
advanced  stage  of  the  disease,  though  present,  are  compressed. 
Under  the  microscope,  a bit  of  yellow  or  orange-coloured  fatty 
liver  appears,  according  to  Albers,  like  a pale-white  sponge,  which 
contains  individual  bladders  of  clearer  colour  with  viscid  fluid,  and 
there  are  dispersed  in  various  points  remote  from  each  other  indi- 
vidual dark-brown  punctula.  These  he  regards  as  the  atrophied 
acini  of  the  liver.  In  the  portions  of  the  liver  retaining  their  red- 
dish-shaded  colour,  these  acini  are  large,  and  more  in  the  normal 
state,  while  the  morbid  intermediate  tissue  is  neither  so  yellow  nor 
so  abundant.  From  this  circumstance  he  infers  that  the  inter- 
mediate or  cellular  tissue  is  over-nourished  and  enlarged,  or 
hypertrophied ; and  that  by  this  hypertrophy  of  the  cellular  tissue 
the  acini  are  atrophied. 

The  fatty  state  of  the  liver  is  said  to  be  commonly  confined  to 
that  gland  alone ; while  all  the  other  parts  of  the  system  are  atro- 
phied. It  is  observed  most  usually  in  pulmonary  consumption ; 
and  has  been  by  some  supposed  to  denote  the  most  advanced  stage 
of  this  disease.  This  inference  must  nevertheless  be  regarded  as 
erroneous ; since,  on  the  one  hand,  in  many  cases  of  advanced 
consumption,  it  is  not  observed ; and,  on  tbe  other,  the  adipescent 
liver  is  observed  in  persons  who  have  not  died  of  consumption. 

Analysis  shows  that  the  adipescent  liver  contains  matter  which 
is  something  a little  different  from  pure  animal  fat.  Andral  found 
that  it  was  almost  entirely  cholesterine ; and,  according  to  Vau- 
quelin,  in  100  parts,  45  consist  of  oil,  19  of  parenchyma,  and  36  of 
water. 

The  size  and  weight  which  the  adipescent  liver  may  acquire  va- 
ries fi’om  five  to  eight  or  nine  pounds,  lu  one  remarkable  case,  in 
which  I recognized  the  disease  during  life  in  a young  female  la- 


902 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


bouring  under  consumption,  the  liver  descended  fully  three  inches 
below  the  margin  of  the  right  hypochondre,  approaching  close  on 
the  crest  of  the  os  ileum^  extended  into  the  epigastric  region,  which 
it  might  be  said  to  fill,  and  a little  into  the  left  hypochondriac  re- 
gion. Its  weight  was  nearly  eight  pounds. 

On  the  pathological  causes  of  this  transformation,  nothing  is  cer- 
tainly known.  Pathological  speculations  have  appealed  to  the  fat- 
tened liver  of  the  goose,  to  show  that  it  is  produced  by  overfeed- 
ing and  too  little  corporeal  exertion ; and  unquestionably  this  may 
give  rise  to  the  transformation.  But  the  change  has  been  observed 
in  the  bodies  of  persons  who,  if  well  fed,  have  not  been  under- 
woi’ked.  Again,  it  is  seen  in  those  who  are  corpulent,  and  who 
are  addicted  to  the  use  of  nutritious  food  and  spirituous  and  fer- 
mented liquors.  Its  occurrence  in  consumption  is  supposed  to  de- 
])end  on  the  obstructed  state  of  the  circulation  through  the  lungs, 
on  the  diminished  power  of  decarbonization  thus  induced,  and  on 
the  greater  quantity  of  blood  believed  to  be  sent  to  the  liver,  and 
the  greater  amount  of  duty  thrown  upon  that  organ. 

The  liver  in  its  sound  state  is  said  always  in  the  adult  to  show 
that  its  acini  contain  oil  and  fat  globules,  which  are  further  said  to 
be  most  abundant  in  those  who  use  fat  and  oleaginous  articles  of 
food.  It  is  possible  that  this  may  be  one  of  the  sources  of  the  adi- 
pose infiltration.  Another  is  more  evident.  The  bile  certainly 
is  liable  by  some  means  to  have  its  elements  converted  into  cho- 
lesterine ; and  it  is  reasonable  to  suppose,  that,  in  the  transition  to 
this  decomposition,  its  elements  may  be  converted  into  fat. 

Another  illustration  of  this  subject  I add  from  comparative  ana- 
tomy. The  livers  of  all  the  finny  tribes  abound  in  oil  to  so  greati 
extent,  that  it  is  one  of  the  products  of  spontaneous  decomposition. 
It  is  most  likely  that  the  separation  and  deposition  of  oil  in  this] 
organ  is  connected  with  the  mode  of  respiration  presented  by  this] 
class.  Gills  are  evidently  less  favourable  to  the  elimination  ofj 
much  carbonaceous  matter  than  lungs  ; and  while  a small  part  of  J 
the  carbonaceous  matter  is  separated  by  the  gills,  part  may  also,  in 
union  with  hydrogen,  be  separated  by  the  liver. 

As  this  disease  is  generally  associated  with  others,  as  pulmonary 
consumption,  its  external  effects  are  not  well  known.  Various 
symptoms  indicative  of  indigestion  are  said  to  denote  its  first  for- 
mation. But  as  upon  these  no  reliance  can  be  placed,  I do  not 
mention  them.  It  is  known  in  its  advanced  stage  by  the  swelling 

6 


CONCRETIONS  OF  THE  DUCTS. 


903 


in  the  right  hypochondi’iac  and  epigastric  region,  which  is  uniform, 
smooth,  and  emits  a dull  sound  on  percussion,  while  pain  is  often 
considerable  in  the  epigastric  region.* 

§ 13.  Concretions  in  the  Ducts. — Under  certain  circum- 
stances the  ducts  of  the  liver  are  filled  more  or  less  completely  with 
concretions,  which  appear  to  be  either  bile,  or  that  product  in  a 
state  passing  to  the  formation  of  biliary  concretions.  Concretions 
may  be  formed  in  any  part  of  the  course  of  the  secreting  and 
excreting  apparatus  of  the  liver ; 1st,  in  the  upper  or  terminal 
ends  of  the  pori  or  small  ducts ; 2d,  in  the  middle  sized  ducts 
which  form  the  hepatic  duct ; 3rf,  in  the  hepatic  duct ; 4f/i,  in  the 
gall-bladder ; 5th,  in  the  cystic  duct ; and,  Qth,  in  the  common 
duct. 

In  the  first-mentioned  situation,  these  concretions  are,  so  far  as 
is  known,  less  common  than  in  the  others.  Cruveilhier  gives  a 
very  good  instance  of  them  in  the  fourth  plate,  book  xii.  of  his  col- 
lection.! These  concretions  appear  under  the  aspect  of  grains  of 
a deep  gi-een  colour,  irregular  in  shape  and  size,  disseminated 
through  the  sound  structure  of  the  gland,  the  yellow  colour  of 
which  forms  a strong  contrast  with  that  of  the  grass-green  colour  of 
these  bodies.  No  information  is  given  as  to  the  chemical  nature 
of  these  bodies ; but  from  their  colour,  it  may  be  inferred  that  they 
are  nearly  pure  bile.  The  glandular  substance  of  the  liver  ap- 
pears of  a deeper  yellow  colour  than  natural ; a condition  probably 
to  be  ascribed  to  the  obstruction  in  the  ducts  preventing  the  bile 
from  descending. 

In  some  livers,  especially  in  those  of  children,  tubercular  bodies 
are  occasionally  found  disseminated  in  minute  grains  through  the 
substance  of  the  liver.  These  grains  are  deposited  in  the  terminal 
portions  of  the  ducts ; and  it  is  the  opinion  of  Cruveilhier  that  they 
are  the  result  of  the  formation  now  mentioned,  namely,  biliary 
concretions.  The  ducts  in  which  these  bodies  are  thus  formed  are 
usually  dilated  into  cysts ; while  the  ducts  below  these  dilated 
portions  may  be  entirely  obliterated.  It  seems  not  unlikely  that 
this  obliteration  of  these  ducts  may  have  been  caused  by  inflamma- 
tion at  some  previous  period,  and  that  this  obliteration  may  thus 

* Einiges  zur  Pathologie  unci  Pathologischen  Anatomie  der  Leber.  Von  J.  F.  H. 
Albers,  Professor  der  Medizin  in  Bonn.  Riist’s  Magazin  fur  die  Gesammte  Heil- 
kunde,  S3  Band,  3 Heft,  Seite  Sll.  Berlin,  1839. 

t Anatomie  Pathologique,  Livi-aison  xii.  Planch  4.  Paris,  1828-1833. 


904 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


be  the  cause  of  the  formation  of  the  concretions  and  the  cysts  in 
which  they  are  inclosed. 

§ 14.  Akinopyesis.  Suppuration  of  the  Acini, — These  ter- 
minal ends  are  nevertheless  subject  to  inflammation,  so  as  to  form 
an  immense  number  of  minute  abscesses  in  the  substance  of  the 
liver.  Cruveilhier  gives  an  instance  in  a female  of  45,  who  had 
jaundice  with  febrile  symptoms  for  10  days  previous  to  admission  to 
hospital.  The  symptoms  proceeded,  notwithstanding  the  use  of  re- 
medies ; and  at  the  end  of  55  days  she  died,  that  is,  65  days  after 
the  appearance  of  the  jaundice. 

It  was  then  found,  besides  two  pounds  of  greenish  serum  in 
the  abdominal  cavity,  that  the  liver,  though  natural  in  size,  was  of 
an  olive  colour,  and  adhered  intimately  to  the  diaphragm,  the 
duodenum,  and  the  transverse  arch  of  the  colon ; that  the  whole 
surface  of  the  liver  presented  a yellowish-white  marbling ; that  the 
lower  surface  presented  two  small  abscesses,  which  were  on  the 
point  of  bursting  into  the  peritoneal  cavity  ; and  that  the  substance 
of  the  gland,  when  divided  by  the  knife,  brought  into  view  nume- 
rous small  abscesses,  containing  purulent  mucus  thickened,  orange- 
yellow,  deep-green,  and  greenish.  These  small  abscesses  had  no 
determinate  shape.  Some  were  formed  by  an  enlarged  biliary  ter- 
minal duct ; others  by  a duct  dilated  and  perforated ; others  by 
sevei'al  dilated  and  perforated  terminal  ducts,  communicating  mu- 
tually so  as  to  form  multilocular  abscesses.  The  adjoining  sub- 
stance of  the  liver  was,  he  states,  not  sensibly  inflamed.  Yet  these 
abscesses  were  in  thousands,  not  throughout  uniformly,  but  mostly 
in  the  right  lobe  of  the  liver. 

The  ductus  clioledochus^  narrow  at  its  duodenal  end,  was  dilated 
immediately  above,  and  contained  a concretion  which  imperfectly 
filled  its  cavity ; and  at  this  point  a slough  in  the  walls  of  the  duct 
had  been  formed. 

This  appears  to  be  an  example  of  inflammation  of  the  terminal 
ends  of  the  biliary  ducts,  confined  mostly  to  these  bodies,  and  not 
extending  beyond  them.  The  inflammation  Cruveilhier  ascribes  to 
irritation,  partly  from  distension  of  the  ducts  by  the  bile  not  per-, 
mitted  to  descend ; and  which,  there  detained,  is  liable  to  form 
miliary  hepatic  concretions.* 


§ 15.  Entozoa. — a.  Parasitical  animals  have  been  observed  in  the 
liver  by  many  anatomists.  In  the  livers  of  the  lower  animals 
* Analomie  Pathologique,  Livraison  xL  Plate  1.  1839. 


PARASITICAL  ANIMALS  IN  THE  LIVER.  HYDATIDS.  905 


these  entozoa  are  very  frequent ; and  the  fluke,  {Distoma  hepati- 
cum^)  especially,  is  seen  often  in  the  bile  ducts  of  the  liver.  This  is 
a broad,  flat,  lancet-shaped  animal,  from  one  to  four  lines  long,  and 
half  a line  to  one  line  broad,  which  generally  is  found  within  the 
hepatic  ducts  and  their  branches.  This  animal  has  been  found 
in  the  liver  of  the  ox,  the  pig,  the  hare,  and  in  that  of  man. 
In  the  last,  however,  it  is  greatly  more  rare.  It  was  seen  by  Mal- 
pighi, Bauhin,  Wepfer,  Pallas,  Chabert,  Bucholz,  and  Brera. 

The  presence  of  these  animals  causes  some  enlargement  of  the 
hepatic  tubes,  and  consequent  irregularity  on  the  surface  of  the 
liver.  In  the  lower  animals,  the  walls  of  the  tubes  become  ossified, 
and  after  some  time  the  parasites  die. 

b.  The  hydatid,  {acephalocystis\  is  by  far  the  most  common  para- 
site in  the  human  liver ; and  while  numerous  instances  of  it  are 
recorded,  it  is  of  no  unfrequent  occurrence.  The  liver,  also,  is 
the  most  common  locality  of  these  animals  in  the  human  body. 

Of  the  acephalocyst  there  are  two  sorts  or  species ; one  the 
manifold  acephalocyst,  (yicephalocystis  socialis ;)  the  other  the  soli- 
tary, (acephalocysiis  eremita  vel  solitaria.') 

In  the  former  case  numbers  of  hydatids  are  found  in  one  or 
more  cysts  in  the  liver.  In  the  latter  in  general  only  one  or  two 
large  hydatids  are  found. 

The  acephalocyst  appears  in  the  shape  of  a globular  or  roundish 
bladder,  or  a cubical  shaped  bladder  with  truncated  and  round- 
ed corners. 

In  the  manifold  or  social  hydatid,  the  figure  is  in  gene- 
ral round  or  globular  ; but  by  pressure  on  each  other  the  figure 
is  often  irregular.  One  large  hydatid  globule  may  contain  twenty 
or  thirty  small-sized  hydatids ; or  fifty  or  sixty  hydatids  of  the 
diameter  of  half  an  inch  or  three  quarters  may  be  contained  with- 
in one  large  cyst. 

In  size  hydatids  vary  from  the  volume  of  a heinpseed  to  that  of 
an  orange,  or  even  larger.  In  the  liver  their  most  usual  size  is 
that  of  a middle-sized  gooseberry ; but  of  course  this  must  depend 
on  the  length  of  time  elapsed  from  their  original  development. 

These  bodies,  whether  large  or  small,  consist  of  a thin,  semi- 
ti'ansparent,  or  transparent,  homogeneous  membrane,  in  which,  by 
the  naked  eye,  it  is  not  possible  to  trace  either  fibrillar  or  vascular 
arrangement,  and  which,  externally,  is  smooth  and  uniform.  In- 
ternally there  are  often  eminences  or  inequalities,  to  which,  in  all 


906 


GENERAL  AND  TATHOLOGICAL  ANATOMY, 


probability,  the  small  hydatids  are  or  were  attached.  As  it  is  not 
possible  in  these  spherical  bladders  to  recognize  either  head  or  tail, 
it  is  from  this  circumstance  that  Laennec  applied  to  them  the  name 
of  acephalocyst. 

Of  the  internal  eminences  some  are  irregular,  white,  more  or 
less  extended  in  surface  ; others  are  spherical,  white,  opaque,  united 
in  greater  or  smaller  number,  and  showing  the  transparence  of  the 
enveloping  cyst  in  their  intervals.  The  smallest  of  these  bodies  have 
no  cavity.  The  largest  have  a small  cavity,  which  enlarges  as  the 
granulation  itself  increases.  In  other  instances  these  granulations 
are  not  opaque,  but  colourless  and  transparent,  like  the  walls  of  the 
acephalocyst  itself.  Lastly,  there  are  some  in  which  colourless 
granules  present  not  rounded  but  varied  forms ; some  elongated, 
others  cuboidal,  others  flattened.  The  largest,  which  approach 
the  globular  figure,  when  punctured,  discharge  a little  serous 
fluid. 

These  bodies,  indeed,  are  the  prolific  gemmules  by  which  the  ani- 
mals are  propagated.  The  cyst  appears  to  be  a general  envelope. 

The  cavity  of  the  acephalocyst  as  seen  in  the  liver  is  filled  by  a 
liquid,  most  commonly  quite  limpid,  and  which  has  all  the  proper- 
ties of  pure  or  slightly  albuminous  water. 

The  acephalocyst,  it  has  been  stated,  contains  others  within  it. 
In  general  one  large  acephalocyst  contains  many  of  smaller  size. 
These  again  contain  others  still  smaller  ; and  it  has  been  inferred 
that  in  this  succession  they  may  pi'oceed  to  a great  extent.  This 
arrangement  is  probably  the  strongest  proof  of  their  living  charac- 
ter ; for  it  appears  to  show  that  one  hydatid  may  produce  many. 

Of  the  animal  nature  of  these  bodies,  the  best  authorities  enter- 
tain little  doubt.* 

* Neither  Rudolphi  nor  Bremser  appear  willing  to  admit  as  a distinct  species  of 
hydatid  the  cysts  described  as  the  acephalocyst.  That  distinction  was  first  made  by 
Laennec  in  1805  and  1814,  and  afterwards  illustrated  by  Liidersen  and  H.  Cloquet, 
and  adopted  by  most  of  the  French  authors.  Laennec,  Rudolphi  mentions  hastily, 
giving  no  opinion  of  the  merits  of  the  distinction.  And  Bremser  states  that  he  lost 
the  notes  which  he  had  made  in  Paris  on  Laennec ’s  dissertation. 

Laennec  distinguishes  these  cysts,  regarding  them  as  animals,  into  three  species  ; 
1st,  The  acephalocyst  rvith  ova  or  true  eggs  ; A.  pyriformis,  simplex,  vesicular  is,  cor- 
porihus  ovatis  praeclita  intus  ; 2d,  The  acephalocyst  with  sprouts  or  gemmulae  : A. 
surculigera,  A.  pyriformis,  simplex,  vesicularis,  surculis  praedita  intus  ; and  3d,  The 
acephalocyst  with  granules  ; A . rjranidosa,  A.  pyriformis,  simplex,  vesicularis,  yranulis 
intus  praedita.  Thus  it  appears  that  these  three  species  differ  ; — in  the  first  presenting  in 
its  walls  small  spherical  white  opaque  bodies,  little  adherent  and  often  hollow  in  the  cen- 


PARASITICAL  AI^IMALS  IN  THE  LIVER.  HYDATIDS.  907 


The  mode  in  which  hydatids  are  formed  in  the  liver  appears  to 
be  twofold.  First,  they  may  be  formed  in  the  peritoneum,  and 
are  attached  to  the  peritoneal  covering  of  the  liver,  forming  round 
tumours,  attached  either  to  the  upper  or  lower  surface  of  the  liver. 
In  this  case  it  is  not  unusual  for  Acephalocysts  to  be  attached  to 
the  intestinal  peritoneum  at  various  points.  Secondly,  the  hydatids 
may  be  developed  within  the  substance  of  the  liver ; and  gradually 
enlarging  by  the  prolific  multiplication  of  their  numbers,  they  may 
form  irregular  elevations  or  tumours  of  considerable  size  at  the  sur- 
face of  the  gland.  They  are  said  to  be  more  common  in  the  right 
lobe  than  in  the  left ; but  in  this  there  seems  to  be  nothing  regular. 
They  may  occupy  both  lobes  at  once. 

Hydatids  when  thus  formed  may  undergo  changes  in  themselves, 
or  they  may  induce  changes  in  the  surrounding  tissue  of  the  liver. 

In  certain  circumstances,  the  fluid  which  the  membranous  cysts 
contain  becomes  thick  and  jellydike.  The  hydatids  may  die,  and 
then  the  membranous  coverings  usually  become  opaque,  thick,  and 
indurated,  sometimes  almost  horny.  In  both  cases  apparently  they 
induce  inflammatory  irritation  in  the  substance  of  the  liver,  fol- 
lowed by  suppuration ; and  they  may  in  this  manner  ulcerate  their 
way  outward,  either  into  the  mucous  surface  of  the  alimentary  canal, 
the  duodenum,  or  the  transverse  arch  or  ascending  portion  of  the 

tre  ; the  second  presenting  at  its  two  surfaces  small  geranvudae  or  buds,  very  irregular 
and  varied  in  shape,  scarcely  visible,  and  of  the  size  of  a hemp  seed  ; and  in  the  third 
being  covered  interiorly  with  transparent  granulations  of  the  size  of  a millet  seed. 
Though  in  appearance  little  different,  these  three  sorts  of  acephalocyst  are  never  found 
i'.i  the  same  cyst.  (Bulletins  de  I’Ecole  de  Medecine,  a Paris,  an  13.) 

Rudolphi  had  read  the  dissertation  of  Liidersen  and  formed  an  opinion  of  it.  Lii- 
dersen  had  found  in  the  interior  of  hydatid  cysts,  as  others  have  done,  innumerable  ve- 
sicular granules,  which  could  not  be  referred  to  the  head  of  Echinococci  ; and  these, 
therefore,  after  Laennec,  he  denominates  human  acephalocysts  ; which, Rudolphi  adds, 
perhaps  may  be  admitted.  (Henrici  Caroli  Ludovici  Liidersen  Dissertatio  de  Hydatidi- 
bus.  GottingiE,  1808.)  But  if  these  hydatids  are  taken  for  animals,  says  Rudolphi,  it  is 
a mistake  ; for  they  are  void  of  certain  organs,  proper  motion,  and  therefore  of  life. 
The  acephalocyst  of  the  hog  Rudolphi  refers  to  the  head  of  Echinococcus.  And  the 
same,  he  adds,  is  either  always  or  sometimes  true  of  the  human  acephalocyst.  “ De 
acephalocystide  humana  idem  forsan  semper  aut  quandoque  valet  ; ipse  saltern  hyda- 
tidibus  compluribus  hepati  debitis,  ab  aegro  deorsum  dejectis,  solicite  examinatis,  ver- 
miculos  sed  rarius  in  iisdem  offendi.”  (Entozoorimr  sive  Vermium  Intestinalium  His- 
toria  Naturalis.  Auctore  Carolo  Asmundo  Rudolphi,  Vol.  I.  and  II.  Amstela;dami, 
1808  et  1810.  Vol.  II.  part  ii.  3G7.) 

De  Blainville  is  of  opinion  that  acephalocysts  ought  to  be  arranged  neither  with  the 
Taenia  hydatigcna,  or  with  the  Cocnurm  or  Echinococcas,  but  that  they  should  be  pla- 
ced near  the  Monadarire  in  the  type  of  Amorphozoa. 


908 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


colon,  or  to  the  surface  of  the  body.  When  they  cause  progressive 
ulceration  into  any  part  of  the  intestinal  canal,  they  are  generally 
discharged  through  the  rectum.  Sometimes  there  is  reason  to  be- 
lieve,"if  situate  near  the  upper  surface  of  the  liver,  they  may  cause 
inflammation  and  ulceration  through  the  diaphragm  into  the  lungs, 
and  be  thence  expelled  by  cough  and  expectoration.  Lastly,  in  se- 
veral instances,  they  have  come  to  the  surface  of  the  body,  and 
formed  a pointing  fluctuating  tumour,  on  puncturing  which  the 
escape  of  purulent  matter  containing  the  debris  of  hydatids,  has 
shown  the  true  nature  of  the  case.  Of  this  latter  termination,  va- 
rious cases  are  recorded  by  Heuerman,  Rebentisch,  Yeats,  Sher- 
win,*  Placido  Portal,!  and  other  observers. 

c.  Echinococcus. — Another  of  this  family  of  parasitical  animals, 
much  more  rare,  is  found  in  the  liver.  The  Echinococcus  is  a ve- 
sicular parasite  with  a pyriform  body,  globular,  or  round  at  head, 
and  with  the  caudal  extremity  much  narrower,  but  also  rounded. 
The  head  is  furnished  with  a circlet  or  ring,  surmounted  by  a row 
of  booklets  or  prominent  spikes,  slightly  incurvated  at  the  extre- 
mity,— the  whole  apparatus  forming  a sort  of  diadem  or  coronet. 

Of  the  occurrence  of  this  animal  in  the  liver  only  three  cases  are 
recorded.  One  is  contained  in  the  Museum  of  the  College  of  Sur- 
geons, London,  and  was  originally  in  the  possession  of  John  Hunter. 
The  second  occurred  to  Mr  Rose  of  Swaffham,  who  observed  them 
in  the  purulent  discharge  from  an  abscess  in  the  liver,  which  be  had 
opened.!  instance,  the  Echinococci  were  associated  with  ace- 

phalocysts.  The  third  is  recorded  by  Mr  Curling,  who  found  them 
in  a cyst  in  the  left  lobe  of  the  liver,  in  the  body  of  a man  aged  71, 
who  had  died  in  the  London  Hospital  of  disease  of  the  urinary 
organs.  § 

As  the  cyst  in  this  last  case,  when  first  opened,  presented  the 
usual  appearances  of  the  acejihalocyst,  and  the  peculiar  characters 
of  the  inhabitants  of  the  cyst  were  only  ascertained  by  microscopi- 
cal examination,  it  comes  to  be  a question,  whether,  in  many  other 

* Case  of  a very  large  Abscess  containing  Hydatids  connected  with  the  Liver  ter- 
minating favom-ably.  By  H.  C.  Shenvin.  Edin.  Med.  and  Surg.  Journal,  Vol.  xix. 
p.  223.  Edinburgh,  1823. 

•f-  Annali  Universal!  di  Medicina,  Vol.  xcvii.  1841. 

J On  the  Vesicular  Entozoa,  and  particularly  Hydatids.  By  C.  B.  Rose,  Swaffham, 
Norfolk.  London  Medical  Gazette,  Vol.  xiii.  p.  204.  London,  1834. 

§ A case  of  a rare  species  of  Hydatid  ( Echinococcus  Hominis ),  found  in  the  Human 
Liver  By  T.  B.  Cmding,  Esq.  Medico-Chirurgical  Transactions,  Vol.  xxiii.  p.  385. 
London,  1840. 


HETEROLOGOUS  GROWTHS. 


909 


instances  of  large  cysts  like  those  of  the  acephalocyst,  they  may  not 
belong  to  the  same  animal. 

In  this  instance  the  mode  of  generation  is  different.  In  the 
echinococcus,  the  yonng  animal  is  formed  between  the  layers  of  the 
parent  cyst,  and  is  detached  from  the  external  surface  of  the  inner 
layer. 

§ 16.  Hygroma. — It  is  doubtful  whether  serous  cysts  are  formed 
in  the  liver ; and  it  may  be  argued  that  any  instances  of  this  kind 
are  to  be  referred  to  the  head  of  Hydatids,  especially  that  named 
the  solitary  acephalocyst.  The  circumstance  is  certainly  not  com- 
mon, and  not  very  well  authenticated.  Cases  referable  to  the 
head  of  Cysts  are  nevertheless  recorded  by  Dr  Todd,*  and  Dr 
Stocker.f  An  instance  is  believed  to  be  given  by  Dr  Hesse,  in 
Horn’s  Archiv,  in  which  a female  of  42,  unmarried,  was  affected, 
some  years  after  a fall  on  the  right  hypochondre,  with  a fluctuating 
swelling  as  large  as  the  head  of  an  infant.  This  tumour  was  punc- 
tured ; and  large  quantities  (five  pounds)  of  serous  fluid  escaped 
without  any  trace  of  relics  of  hydatids.  The  patient  did  not  recover, 
but  died  one  year  after  the  operation.  It  was  then  found  that  the 
liver  was  very  much  enlarged ; and  that  the  right  lobe  contained  a 
large  cyst,  which,  when  divided,  allowed  to  escape  twelve  pounds  of 
serum,  at  first  watery,  then  turbid  and  flocculent.t 

Mr  Caesar  Hawkins  describes  certain  encysted  tumours  as  form- 
ing on  the  margin  and  at  the  surface  of  the  liver,  and  occasionally 
sinking  into  its  substance,  and  seldom  exceeding  the  size  of  a Al- 
bert, or,  at  most,  a walnut.  These  tumours  contain  clear  semi- 
transparent or  pellucid  liquid,  scarcely  coagulable  by  heat,  and  in 
which  there  is  found  a peculiar  animal  matter,  named  by  Dr  IMar- 
cet  muco-extractive.§ 

According  to  Mr  Hawkins,  these  cysts  rarely  secrete  purulent 
matter  ; and  when  this  fluid  is  formed  in  them,  it  is  not  of  a healthy 
character. 

§ 17.  Heterologous  Growths. — A.  Of  these  it  has  been  ob- 
served, that  occasionally  one  or  other  of  the  encysted  tumonrs, 

* Dublin  Hospital  Reports,  VoL  L p.  325. 

-j-  Transactions  of  the  College  of  Physicians  in  Ireland,  Vol.  i.  p.  11. 

•]-  Horn’s  Archiv,  Septembre  und  Octobre  1839. 

§ Cases  of  Sloughing  Abscess  connected  with  the  Liver,  with  some  remarks  on  En- 
cysted Tumours  of  that  Organ.  By  Casar  Hawkins,  Esq.  Medico-Chirurgical  Trans- 
actions, Vol.  xviii.  p.  98.  London,  1833. 


910  GENERAL  AND  PATHOLOGICAL  ANATOMY. 

Meliceris*  Athermna^-\  and  Steatoma,%  were  formed  in  the  liver, ' J 


The  instances  nevertheless  are  not  well  authenticated,  and  were 
recorded  at  periods,  when  accurate  distinctions  had  not  been  intro- 


informed  authorities  to  he  degenerated  acephalocysts ; and  those  of 
the  last  belong  mostly  to  the  encephaloid  deposit. 

B.  Struma. — Whether  struma  be  always  regarded  as  a hetero- 
logous product  or  not,  tubercle  is  usually  considered  as  such. 
Struma,  however,  does  not  appear,  in  all  instances,  in  the  form  of 
tubercle  in  the  liver.  It  may  take  place  in  that  of  a sort  of  infil- 
tration of  strumous  deposition  in  the  interstitial  matter  of  the  gland. 
Its  appearances  are  then  the  following.  The  liver  is  enlarged,  mostly 
in  the  transverse  direction,  with  some  flattening  of  the  two  surfaces. 
It  is  also  heavier,  i.  e.  from  five  to  six  or  eight  pounds.  The  peri- 
toneum is  smooth  and  tensely  stretched.  The  liver  is  doughy; 
generally  of  a pale  yellow  or  grayish-red  colour,  sometimes  a little 
variegated,  and  not  vascular.  The  section  is  smooth,  homogeneous,* 
a little  lardaceous  looking,  but  not  leaving  greasy  traces  on  the 
knife ; and  little  blood  escapes,  while  a serous  muddy  liquor  oozes 
from  points  of  the  section.  The  substance  is  in  general  friable, 
flaccid,  and  lacerable. 


pathological  causes  of  this  change ; and,  when  its  physical  charac- 
ters are  stated,  it  is  almost  all  that  can  be  predicated  regarding  the  '/ 
lesion  without  committing  errors.  A new  matter  is  infiltrated  into 
the  interstitial  tissue  of  the  gland  ; but  what  that  new  matter  is,  is 
not  known. 

This  lesion  takes  place  in  persons  wasted  by  disease,  and  with 
other  marks  of  strumous  disposition.  It  is  observed  in  children 
and  young  persons  who  have  enlarged  mesenteric  glands  ; and  in 
those  who  are  phthisical.  It  occasionally  proceeds  to  abdominal 
dropsy.  Yet  life  may  be  prolonged  for  a considerable  time  with 
this  disorder.  Many  years  ago,  I performed  several  times  the  ope- 
ration of  paracentesis  on  a young  man  labouring  under  this  disease, 
which  had,  at  the  time  referred  to,  been  of  some  duration.  In  ge- 

* Bianclii,  Hist.  Hepatica.  p.  ID 7. 

t Columbus,  Glisson,  and  Bianchi,  Hist.  Hepat.  Guettard,  Baader. 

+ Columbus  de  Re  Anatomica.  Bianchi,  Hist.  Hepat.  Biumi  apud  Sandifort,  Dis- 
sertat.  Enaux. 


duced.  Instances  of  the  first  and  second  are  believed  by  the  best 


Nothing  positive  or  certain  is  known  regarding  the  anatomico- 


STRUMOUS  TUBERCLES.  ENKEPHALOBIA. 


911 


neral,  however,  it  proves  fatal,  partly  by  the  imperfect  digestion 
from  want  of  proper  bile,  and  partly  by  the  abdominal  dropsy. 

C.  Tubercles. — Bodies  quite  similar  to  the  tubercular  masses 
of  the  lung  have  been  observed  in  the  liver ; and  these  are  then  to 
be  viewed  as  the  tubercular  form  of  struma.  In  other  instances 
strumous  abscesses,  like  those  already  described,  may  be  regarded  as 
the  softening  or  liquefying  stage  of  the  tyromatous  deposit.  Baillie, 
however,  admits  that  tubercle  is  a rare  disease  of  the  liver.  They 
appear  to  have  been  observed  by  Portal  who,  however,  has  spoken  of 
them  as  gelatiniform  mucous  and  albuminous  formations  within  the 
liver.  A case  in  a person  of  19  is  given  by  Dr  Bramer  of  Cassel.* 

The  soft  brown  tubercles  of  the  liver,  mentioned  by  Baillie  as  bo- 
dies situate  at  or  near  the  surface  of  the  liver,  and  consisting  of 
smooth  soft  brownish-coloured  matter,  appear  to  have  been  either 
clots  of  blood,  the  effects  of  hemorrhage,  or  instances  of  melanosis. 

D.  SciRRHUS  AND  Enkephaloma. — Though  instances  of  scir- 
rhus  are  represented  by  many  writers  to  have  been  found  in  the 
liver,  yet  if  we  apply  the  elucidations  and  distinctions  of  accurate 
observation  and  pathology,  scarcely  one  of  these  can  be  recognized 
as  genuine  examples  of  that  species  of  structure.  I have  already 
shown  that  skleroma  or  simple  induration  and  kirrbosis  have  been 
referred  to  the  head  of  skirrhus  of  the  liver ; and  1 think  it  not 
doubtful  that  any  kind  of  hard  structure  of  unusual  characters  has 
been  considered  as  instances  of  scirrhus.  On  the  whole,  genuine 
skirrhus  is  a rare  formation  in  the  liver  ; and  probably  only  ap- 
pears in  it  by  extension  from  other  organs,  especially  the  stomach. 
From  the  observations  in  the  next  article,  however,  it  must  be  al- 
lowed that  if  genuine  skirrhus  be  not  observed  in  the  liver,  it  has 
its  representative  in  the  kindred  form  of  morbid  structure  called 
Enheplialoma, 

, Enkephaloma  must  be  regarded  as  the  true  form  in  which  skir- 
rhus appears  in  the  liver ; and  in  this  organ  it  is  extremely  common. 

It  appears  in  three  forms,  which  are  probably  only  different  stages 
of  the  same  morbid  change. 

First,  there  are  formed  in  the  liver  irregularly  rounded  nodules,  of 
whitish  or  whitish-gray  matter,  varying  from  the  size  of  a filbert  to 
that  of  a walnut,  or  larger.  When  these  bodies  are  divided,  they 
have  a consistence  between  that  of  cream  cheese  and  the  unboiled  po- 
tato. The  section  is  quite  homogeneous,  and  totally  void  of  any 
* Pabst’s  Allgemeine  medizin.  Zeitung,  1838.  N.  15-19. 


912 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


arrangement  like  vascularity  or  proofs  of  organization.  Examined 
very  minutely  they  present  the  appearance  of  infinitely  minute 
granules  aggregated  together.  The  sections  occasionally  present 
an  appearance  of  fibrons  radiation  very  much  like  that  of  the  ra- 
diated zeolite;  the  fibrous  lines  diverging  and  radiating  either 
from  one  or  two  points  towards  the  periphery  of  the  tumour,  or 
from  a line  passing  through  the  middle  or  centre  of  the  tumour. 

In  some  instances  the  colour  of  these  tumours  internally  is  of  a 
drah-gray,  or  fawn,  or  giraflFe  tint.  But  the  consistence  and  phy- 
sical characters  are  the  same. 

In  general  these  moderately  sized  masses  are  pretty  firm,  softer 
than  the  unboiled  potato,  but  firmer  than  lard,  something  like  new 
cheese  of  moderate  firmness,  but  less  tough  and  more  friable. 

In  another  variety  this  deposit  may  appear  in  the  form  of  irre- 
gularly spherical,  spheroidal,  or  ovoidal  masses,  varying  from  the 
size  of  a filbert  to  that  of  a walnut  or  small  egg,  yet  softer  and 
more  elastic  than  those  last  described,  and  presenting  at  the  surface 
more  or  less  vascularity,  and  not  unfrequently  with  some  vessels 
ramified  through  their  substance.  The  aspect  of  these  is  in  some 
instances  like  a smooth  strawberry  or  raspberry. 

Tumours  of  this  character  proceed  early  to  the  formation  of  fun- 
gous growths,  which  discharge  blood  freely  and  often.  Some  ob- 
servers deny  that  this  is  a softening  process. 

The  consistence  of  these  tumours  is  generally  about  that  of  brain, 
pulpy,  soft,  and  compressible ; and  in  several  parts  they  may  be 
more  pulpy  than  in  others. 

Cruveilhier  distinguishes  this  variety  into  two  subspecies  accord- 
ing to  their  less  or  greater  degree  of  vascularity.  For  this  dis- 
tinction there  may  be  some  foundation ; but,  if  we  consider  that  a 
degree  of  vascularity  is  the  general  attribute  of  this  form,  it  seems 
unnecessarily  to  multiply  subdivision,  to  derive  the  characters  fro|i 
differences  in  degree  only. 

If  a stream  of  water  be  directed  on  tumours  of  this  species,  the 
soft  pulpy  matter  is  washed  away,  and  nothing  is  left  but  a cellulo- 
vascular  frame-work. 

These  reddish  rasp-like  bodies  are  found  both  at  the  surface  and 
in  the  substance  of  the  liver.  They  are  in  general  formed  in  a 
short  time,  like  all  the  varieties  of  encephaloid  disease ; but  they 
are  peculiar  in  proceeding  rapidly  to  the  formation  of  bleeding 
fungi. 


ENKEPHALOMA  OF  THE  LIVER. 


913 


These  two  forms  of  enkephaloma  appear  to  correspond  with  the 
TtJBERA  Circumscripta  first  well  described  by  Dr  Farre, 

Though  I describe  these  two  forms  of  enkephaloid  disease  as 
appearing  usually  in  small  masses  of  definite  size,  yet  it  does  not 
follow  that  they  may  not  be  larger.  Two  or  more  masses  may  be 
growing,  and  extending,  may  coalesce,  and  thus  form,  instead  of 
twenty  or  thirty  small  tuberosities,  five  or  six  large  irregular-shaped 
masses.  In  short,  I have  strong  reason  to  believe  that  neither 
colour  nor  size  are  essential  and  invariable  characters ; and  that 
the  same  structure  may  appear  sometimes  in  small  nodules,  some- 
times in  large  masses,  and  that  its  colour  may  vary  from  tallow- 
white  to  light  fawn. 

A third  form  which  the  disease  assumes  is  the  following. 

Large  irregularly  rounded  masses,  generally  of  a whitish  colour, 
are  formed  in  the  substance  of  the  liver,  projecting  from  its  surface, 
and  rendering  that  surface  irregular  and  firm.  These  masses  vary 
in  volume  from  the  bulk  of  a middle-sized  potato  to  that  of  a large 
orange.  They  are  never  exactly  spherical,  but  only  irregularly 
rounded,  oblong,  or  quite  incapable  of  being  referred  to  any  ordi- 
nary known  figure. 

These  masses  are  so  large  as  not  only  to  alter  very  much  the 
shape  of  the  liver,  but  to  encroach  extremely  on  the  original  struc- 
ture of  the  organ.  When  the  liver  is  divided,  the  sections  show 
that  the  morbid  deposition  has  extended  throughout  the  whole  gland. 

These  masses  are  whitish,  or  whitish  gray  in  colour,  firm,  of  a con- 
sistence between  tallow  and  cheese  ; and  the  section  has  some  re- 
semblance to  that  of  the  unboiled  potato  or  yam.  The  section  is 
not  quite  so  homogeneous  and  uniform  as  that  of  the  small  tube- 
rosities, and  it  presents  more  or  fewer  minute  cavities  containing 
a sero-gelatinous  liquid  which  readily  oozes  from  them.  Traces 
of  organic  arrangement  cannot  be  distinctly  recognized;  yet,  in 
some  instances,  one  or  two  large  varicose-like  vessels  may  be  seen 
passing  through  the  mass.  In  some  instances  the  appearance  of 
radiating  fibres,  like  that  of  zeolite,  may  be  seen  as  in  the  small- 
sized tuberosities.  But  this  is  less  frequent  than  in  the  latter.  The 
radiating  appearance  also  is  greatly  less  regular,  and  often  ap- 
pears in  the  form  of  irregular  lines  or  fibres. 

The  shape  and  outline  of  these  masses  is  irregularly  round,  or 
globular,  or  spheroidal,  and  often  so  irregular  that  it  is  impossible 
to  compare  them  to  any  known  figure.  In  some  instances  two  or 
three  masses  appear  to  have  coalesced  into  one  continuous  mass, 

3 M 


914 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


and  in  this  manner  to  have  rendered  the  figure  of  the  whole  still 
more  irregular. 

In  size,  the  masses  now  described  are  generally  large ; that  is 
from  the  size  of  an  apple  or  orange,  to  three  or  four  times  that 
magnitude. 

The  masses  now  described  form  the  tuhera  circumscripta,  and  the 
tuber  a diffusa  of  Dr  Farre,  who  first  after  Baillie  gave,  in  1812,  a 
particular  account  of  these  growths.  Those  first  described,  or  the 
small-sized  tumours,  are  the  tuhera  circumscripta ; those  last  de- 
scribed are  the  tuhera  diffusa.  For  this  distinction  the  reasons  ap- 
pear not  satisfactory.  The  tuhera  circumscripta,Y)x  Farre  believed 
to  be  confined  chiefly  to  the  liver,  while  the  tuhera  diffusa  might 
affect  not  only  the  liver,  but  all  other  organs.  We  now  know  that 
though  the  former  growth  appears  most  commonly  in  the  liver,  yet  | 
it  is  not  confined  to  that  organ ; and  we  know  also  that  both  are  ^ 
mere  varieties  of  the  same  morbid  deposition.  ?! 

The  disease  has  been  regarded  and  described  as  the  same  as  the 
medullary  sarkoma  or  fungus,  and  the  hematoid  fungus;  and^ 
probably  it  is.  But  though  it  bears  a close  resemblance  to  this  in 
the  great  rapidity  of  its  growth,  and  its  mode  of  invading  the  sub- 
stance of  organs,  it  is  in  some  respects  different  from  this.  The 
most  probable  view  is,  that  the  medullary  fungus  is  the  advanced 
stage  of  the  enkephaloid  tumour. 

The  microscopical  structure  of  enkephaloma  has  been  examined 
by  Muller  and  Vogel,  under  the  name  of  the  medullary  fungus. 
According  to  both,  the  tumour  consists  of  nucleated  cells,  round, 
oval,  caudate,  varying  in  magnitude  from  part  of  a line  tOj^Q.' 
Some  contained  a nucleolus  within  a nucleus.  By  addition  of  vine-^ 
gar  these  cells  become  pale,  and  the  nuclei  and  nucleoli  are  more 
distinctly  brought  into  view.*  Gluge  states  that  enkephaloma  con- 
sists of  clear  serum,  and  very  numerous  white  spherical  globules, 
which  show  no  nucleus,  but  a ragged  undulating  surface,  or  they  are 
colourless  and  even.  These  globules  are  larger  than  pus-globules. | 
The  fluid  contains  crystals. 

From  the  circumstance  of  enkephaloid  tumours  presenting  these  ^ 
nucleated  cells  as  other  tissues,  Muller  infers  that  they  are  not?, 
heterologous  growths.  But  this  does  not  touch  the  question.  The  J 

* Ueber  den  feinem  Ban  und  der  Fonnen  der  Krankhaften  Geschwiilste  von  Dr  Jo- 
hannes Miiller  in  Zwei  Lieferungen.  Erste  Lieferung.  Berlin,  1838. 

Julli  Vogel  leones  Histologiae  Pathologicae.  Tabula,  vi.  Histologiam  Pathologicam 
Illustrantes.  Lipsias,  1843. 

t Atlas  des  Pathologischen  Anatomie.  Erste  Lieferung.  Jena,  1843. 


ENKEPHALOMA  OF  THE  LIVER. 


915 


cells  may  be  the  same ; yet  the  structure,  that  is,  the  arrangement 
and  contents  of  the  cells,  may  be  totally  different.  The  question  is 
further  one  which,  it  is  clear,  the  microscope  is  not  adequate  to  deter- 
mine, Careful  comparison  of  the  enkephaloid  structure  shows  that 
it  resembles  neither  cellular  tissue,  nor  fat,  nor  lard,  nor  brain,  nor 
gland,  nor  cartilage,  nor  bone,  but  is  peculiar  in  resembling  itself 
alone,  and  in  undergoing  peculiar  changes. 

Enkephaloma  appears  in  the  liver  in  several  different  modes. 

First^  It  may  appear  in  that  gland  and  in  no  other  tissue  ; and 
the  masses  may  gradually  enlarge  until  they  coalesce  and  occupy 
the  largest  portion  of  the  hepatic  structure.  They  may  attain  a 
considerable  size  before  the  fatal  event  takes  place. 

Secondly^  Encephaloma  may  appear  in  the  liver  along  with  or  after 
the  development  of  enkephaloid  tumours  in  one  or  more  of  the  abdo- 
minal viscera,  or  in  the  interperitoneal  and  mesenteric  cellular  tissue. 

Thirdly^  A mode  not  unusual  in  which  it  appears  is  the  follow- 
ing. A tumour  of  suspicious  character  appears  in  the  breast  of  a 
female,  and  after  some  time  it  is  removed  by  the  surgeon.  The 
wound  is  healed ; but  in  the  course  of  eight,  ten,  or  twelve  months, 
the  patient  complains  of  tightness  and  fulness  in  the  right  hypochon- 
driac region,  and  in  the  abdomen  generally.  In  the  former  there 
is  irregular  swelling;  fluid  is  effused  within  the  abdomen;  and 
after  two  or  three  months  more,  death  ensues.  The  liver  is  found 
quite  occupied  with  large  enkephaloid,  whitish,  or  whitish  gray 
masses.  The  same  structure  affects  the  diaphragm,  and  spreads 
into  the  lower  lobe  of  the  right  lung.  This  I have  seen  take  place 
more  than  once.  The  tumour  removed  from  the  breast  is  not  al- 
ways quite  the  same.  Sometimes  it  presents  the  whitish  lard-like 
structure  of  enkephaloma;  sometimes  it  presents^ the  characters  of 
pancreatic  sarkoma;  and  in  various  instances  it  has  presented 
those  of  alveolar  or  areolar  cancer. 

Fourthly^  Dr  Alder  son  gives  several  examples  of  disease  of  the 
stomach  and  liver,  in  which  the  former  organ  presented  the  areolar 
and  colloid  cancer,  and  the  latter  presented  distinct  and  unequivo- 
cal masses  of  enkephaloid  structure. 

If  all  the  facts  now  adduced  be  well  ascertained  and  constant, 
and  I can  vouch  for  the  truth  of  the  three  first,  it  follows  that  en- 
kephaloma is  allied  to  other  forms  of  cancerous  disease,  and  that  it 
may  be  regarded  as  the  form  which  pancreatic  or  alveolar  cancer 
of  the  external  organs  assumes  in  the  liver.  The  same  morbid 
action  which  produces  the  pancreatic  and  alveolar  deposit  in  the 


916 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


mamma,  and  that  which  produces  the  colloid  structure  in  the  sto-r^^ 
mach,  may  produce  the  encephaloid  deposit  in  the  liver. 


the  neck,  those  of  the  female  breast,  among  the  muscles  of  an  ex- 
tremity,  or  in  a bone  or  joint,  and  also,  either  at  the  same  time  or 
soon  after,  in  the  liver, 

Enkephaloid  deposit  may  affect  the  liver  at  any  period  of  life.  But 
it  appears  most  usually  between  the  ages  of  30  and  45  or  50.  I have 
seen  an  instance  beyond  60 ; but  this  must  be  regarded  as  unusual. 

Death  is  produced,  not  so  much  by  the  mere  nature  of  the  dis 
ease  as  by  its  mechanical  pressure  and  pathological  irritation  o 
the  chylopoietic  and  assistant  chylopoietic  viscera.  The  enlarge 
liver  compresses  the  stomach,  duodenum,  and  blood-vessels ; in 
pedes  the  function  of  digestion  ; and  causes  intra-abdominal  effusioi 

Dr  Carsewell  shows  that  in  many  if  not  all  instances,  the  enk< 
phaloid  matter  is  previously  found  in  the  blood  and  blood-vessels 
and  that  from  the  blood  it  is  conveyed  by  the  vessels  to  various  oi 
gans,  and  especially  to  the  liver.  He  thinks  that  in  the  liver  tl 
enkephaloid  matter  is  infiltrated  or  deposited  within  the  acini,  c 
glandular  elements ; and  as  the  form  and  size  of  these  bodies 
not  altered,  he  infers  that  this  new  matter  is  introduced  in  the  sani 
order  and  manner  as  the  normal  element' of  nutrition,* 


right  hypochondre  and  epigastric  region,  sometimes  extending  dowr 
wards  to  the  space  of  two  or  three  inches,  with  an  irregular  nodulate 
surface,  with  the  peculiar  complexion  and  expression  indicating  th 
presence  of  heterologous  disease,  are  the  marks  which  it  presents. 

E.  Melanoma.  Melanosis. — This,  which  consists  in  a depc 
sition  of  black  ink-looking  or  umber-brown  matter,  semifluid,  solid,*' 
like  black  paste,  or  liquid,  sometimes  in  points,  sometimes  in  masses 
contained  in  cysts,  sometimes  in  layers,  is  an  affection  of  the  liver 
not  very  uncommon.  Yet  it  rarely  takes  place  in  the  liver  unless 
at  the  same  time  or  previously  it  has  taken  place  in  other  tissues. 
The  most  usual  situation  for  the  melanotic  matter  to  he  deposited 
when  it  is  found  in  the  liver,  is  in  the  adipose  tissue  between  the 
folds  of  the  mesentery,  the  mesocolon,  in  that  round  the  rectutn,v 
and  in  the  lumbar  glands  and  loins  in  general.  It  seems  to  be  not 


* Illustrations  of  the  Elementary  Forms  of  Disease.  By  Robert  Carsewell,  M.  D„ 
&c.  London,  1838. 


Fifthly,  It  occasionally  happens  that  the  enkephaloid  structure  ? 
appears  both  in  several  external  parts,  for  instance  in  the  glands  of 


nized  during  life  with  little  difficulty.  A tumour  in  the  site  of  th 


The  presence  of  enkephaloma  in  the  liver  is  in  general  reco^ 


MELANOIIA MELANOSIS  OF  THE  LIVER. 


1)17 


doubtful  that  in  these  parts  it  is  deposited  before  it  is  formed  in  the 
liver.  The  melanotic  deposit  may,  when  forming  in  the  liver,  have 
been  also  previously  deposited  in  organs  still  more  remote,  for  in- 
stance, in  the  adipose  tissue  of  the  eyeball.  Melanoma  is  in  short 
a deposit  which  is  first  formed  in  some  of  the  divisions  of  the  adi- 
pose tissue,  and  then  may  be  formed,  to  all  appearance,  in  a secon- 
dary way,  in  one  or  more  of  the  internal  organs,  most  commonly 
the  liver  or  the  lungs. 

When  melanosis  takes  place  in  the  liver,  it  affects  one  of  two 
forms ; first,  either  the  form  of  black  points  which  are  deposited  in 
the  acini,  or  black  semifluid  or  consistent  masses,  which  may  be  tu- 
beriform,  and  may  be  or  not  contained  within  cysts. 

Melanosis,  viewed  as  a morbid  deposit,  consists  of  a sort  of 
frame-work,  and  a colouring  matter  or  pigment.  The  frame-work 
or  tissue  is  a fibrous  structure  arranged  in  the  areolar  manner,  that 
is,  forming  areolae  or  interstices,  of  a pearly  aspect,  and  which  is 
probably  allied  to  the  fundamental  structure  of  areolar  cancer,  only 
much  softer. 

The  pigment  or  colouring  matter  is  of  two  sorts.  It  may  be 
either  as  black  as  the  ink  of  the  cuttle-fish,  or  it  may  he  of  an  um- 
ber or  bistre-brown  tint.  The  former  is  the  most  frequent.  This 
Thenard  regards  as  charcoal,  and  Barruel  and  Breschet  as  the 
colouring  matter  of  the  blood.  According  to  the  best  analyses, 
those  of  Barruel,  and  Clarion,  and  Lassaigne,  this  colouring  matter 
consists  of  albumen  15  per  cent.,  fibrin  6 per  cent,  carbonaceous 
matter  31  per  cent,  oxide  of  iron  If  per  cent,  and  the  usual  salts 
of  the  blood.  These  facts  give  a high  degree  of  probability  to  the 
opinion  promulgated  by 'Breschet,  that  melanotic  matter  is  blood 
extravasated  and  changed,  with  a large  proportion  of  colouring 
matter.  If  this  be  correct,  it  seems  that  it  is  a mistake  to  regard 
melanosis  as  always  a malignant  or  heterologous  growth.  The 
deposit,  nevertheless,  takes  place  under  circumstances  which  scarcely 
permit  us  to  call  this  in  question.  It  may  be  that  there  is  a simple 
or  innocuous  form  of  melanosis,  and  one  associated  with  the  carci- 
nomatous structure. 

When  melanotic  matter  is  deposited  in  the  liver  so  as  to  present 
the  solid  form,  it  is  usually  in  the  acini ; and  then  it  gives  the  gland 
the  aspect  of  a piece  of  syenite,  or  rather  black  micaceous  rock, 
from  the  peculiar  glistening  aspect  of  the  fundamental  tissue. 

§ 15.  d.  Dr  John  Gairdner  and  Mr  Thomas  M.  Lee  described 
in  1844  a species  of  hydatid,  which,  though  perhaps  noticed  by 


918 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


previous  observers,  had  not  been  accurately  distinguished  or  care- 
fully described.  Though  the  morbid  condition  connected  with  the  ’’  | 
presence  of  this  parasite  was  not  confined  to  the  liver,  and  affected  , [ 
not  merely  the  right  lobe  of  that  organ,  but  the  omentum,  part  of  j;.: 
the  pancreas  and  spleen,  part  of  the  intestinal  canal,  and  the  sur-^  j 
face  of  the  peritoneum  in  general,  yet  it  may  he  well  to  notice^ 
shortly  the  characters  of  the  animal. 

In  the  case  given  by  Dr  Gairdner,  the  hydatids  consisted  of  glo-  H;| 
bular  or  rounded  bodies  aggregated  in  masses  or  groups,  not  un-  tiii 
like  the  egg-bed  of  the  common  fowl.  Each  hydatid  consisted  of  ■ . 
gelatinous  matter  contained  within  striae  or  fibres ; and  each  had  an 
external  membrane  provided  with  stomata,  or  orifices  which  lead  S 
into  tuhvli.  Each  group  consisted  of  many  hydatids  attached  or 
covered  by  one  common  membrane,  which  further  dipped  between^  U 
them.  This  membrane  presented  numerous  disks  varying  in  size,^,, 
and  round  which  the  orifices  or  stomata  were  arranged.  This  it 
has  been  proposed  to  denominate,  from  the  circumstance  now  spe-^^" 
cified,  Diskostoma  acephalocystis. 

In  the  case  which  occurred  to  Mr  Lee,  the  hydatid  had  a gela-^i 
tinous  body  like  the  last  noticed,  and  membranous  investments  pmII 
but  the  animal  itself,  which  varied  in  size  from  a millet  seed  to  the^  ' 
bulk  of  an  orange.  This  animal  is  without  aperture  or  apparent^ 
organ  of  nutrition ; and  hence  it  has  been  proposed  to  term  it^‘ 
Astoma  acephalocystis.  ^ 

Those  under  the  size  of  a filbert  were  globular.  As  soon  as 
they  advance  beyond  this  size,  they  assume  on  the  surface  a nodu- 
lated appearance,  which  increases  with  the  size  of  the  animal,  and 
which  is  owing  to  the  simultaneous  growth  and  enlargement  of  tlie  c 
young  cysts  contained  within  it. 

The  Astoma  acephalocystis  forms  a sort  of  intermediate  link  be-,. '3 
tween  the  common  acephalocyst  {Acephalocystis  simplex)  and  th^ 
Dishosloma  acephalocystis.* 

Some  observers  have  called  in  question  the  independent  animal  ,• 
existence  of  these  two  species  of  parasite,  as  others  have  doubted 
that  of  the  common  acephalocyst.  So  far  as  it  is  possible  to  forin:,^ 
an  inference  from  appearance  and  characters,  they  seem  entitled  to 
be  regarded  as  animals,  though  of  a low  and  imperfect  type ; and 
it  seems  most  convenient  to  notice  them  in  this  place. 

* Cases  and  Observations  illustrating  the  History  of  two  kinds  of  Hydatids,  hitherto  | 
midescribed.  By  John  Gairdner,  M.  D.  and  Thomas  M,  Lee.  Edin.  Medical  and  j 
Surgical  Journal,  Vol.  Ixi.  p.  269.  Edinburgh,  1844. 


DISEASES  OF  THE  GALL-BLADDER  AND  GALL-DUCT.  919 


The  Gall-Bladder  and  Ducts.  The  Bh.e. — § 1.  The  gall- 
bladder, and  cystic  duct,  and  common  duct  are  all  liable  to  inflam- 
mation, sometimes  of  a spreading  and  catarrhal  character,  or  phleg- 
monous and  limited.  In  either  case  the  process  may  cause  a tem- 
porary attack  of  jaundice. 

§ 2.  Hydatids  have  been  found  in  the  gall-bladder.* 

Parasitical  animals,  as  the  Fasciola  hepatica^  it  has  been  already  • 
stated,  may  take  place  in  the  biliary  ducts. 

§ 3.  The  most  usual  and  important  disorder  of  the  biliary  excretory 
system  consists  in  the  formation  of  gall-stones,  which  may  be  form- 
ed in  any  part  of  these  ducts,  and  in  the  gall-bladder,  but  most 
commonly  in  the  latter. 

Gall-stones  occur  of  all  sizes,  from  that  of  a pin-head  up  to  the 
magnitude  of  one  inch  in  diameter.  When  small,  they  are  gene- 
rally numerous,  and  may  occur  to  the  amount  of  sixty  or  seventy 
in  the  gall-bladder  at  one  time.  Their  figure  in  that  case  is  poly- 
hedral or  tetrahedral,  with  rounded  edges  and  angles,  from  mutual 
attrition  and  polishing.  When  there  are  only  two  or  one,  then  the 
size  may  be  considerable,  that  is,  from  half  an  inch  to  three-quar- 
ters of  an  inch,  or  a whole  inch  and  more  in  diameter.  Their 
figure  is  then  spherical,  oblong  spheroidal,  or  pyriform,  more  or 
less  regular.  In  this  state  they  may  be  contained  either  within  the 
gall-bladder,  or  in  certain  dilated  portions  of  the  biliary  ducts. 

These  bodies  are  lighter  than  water.  Soemmering  states  he  has 
seen  them  sink;  yet  his  facts  show  that  they  are  lighter.  They  are  in- 
flammable, and,  when  burned,  are  slowly  reduced  to  charcoal  almost 
pure.  Their  interior  structure  presents  a resinous  glistening  frac- 
ture, and  a yellow  or  yellowish-brown  colour,  and,  when  closely 
inspected,  the  broken  part  exhibits  numerous  minute  brilliant,  crys- 
talline scales,  which  resemble  mica  or  scales  of  spermaceti.  These 
scales  are  almost  pure  cholesterine,  which,  indeed,  constitutes  the 
larger  portion  of  almost  all  gall-stones.  Some  gall-stones  consist 
of  pure  cholesterine ; others  consist  of  cholesterine  with  the  colour- 
ing matter  of  the  bile ; and  a very  small  proportion  contain  the 
matter  of  bile  inspissated  and  altered. 

Cruveilhier  states,  that  in  most  calculi  of  cholesterine,  the  nu- 
cleus consists  of  concretions  of  thickened  bile.  This  does  not  cor- 
respond with  what  is  observed  in  this  country.  In  general,  the 
nucleus  or  central  portion  consists  of  cholesterine  in  more  or  less 
purity,  and  round  this  are  lamellae  or  strata,  still  of  cholesterine 

* Museum  Anatomicum,  a Johanne  Gottlieb  Walter.  Berolini,  1805.  4to,  p.  xix. 


920 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


in  scales,  but  with  colouring  matter  of  bile ; and  the  only  part 
which,  in  a small  proportion  of  cases,  is  inspissated  bile,  is  the  outer 
portion  of  the  concretion.* 

These  facts  regarding  the  chemical  composition  of  biliary  cal- 
culi show  that,  previous  to  their  formation,  a great  and  decided 
change  takes  place  in  the  bile.  Bile  does  not  in  the  normal  state 
contain  cholesterine ; but  there  is  no  doubt  that  the  cholesterine  is 
formed  from  the  bile.  A new  arrangement,  therefore,  of  the  ele- 
ments of  bile  must  take  place.  Cholesterine  consists  principally  of 
carbon  and  hydrogen,  and  the  ingredients  of  the  bile  must  so  alter 
their  relations  as  to  form  in  this  manner  cholesterine. 

The  presence  of  gall-stones  in  the  tubuli,  the  gall-ducts,  or  in  the 
gall-bladder,  gives  rise  to  various  effects  in  these  parts.  The  liiost 
common  is  believed  to  be  jaundice  ; and  eertainly  in  the  case  of  gall- 
stones of  moderate  size  becoming  fixed  in  either  the  tubuli^  the  pori^ 
the  hepatic  duct,  the  cystic  duct,  or  the  common  duct,  more  or  less 
jaundice,  continuing  for  a longer  or  shorter  time,  usually  takes 
place.  On  the  other  hand,  numerous  instances  have  been  recorded 
of  gall-stones  being  discharged  either  by  the  bowels,  or  by  ulcera- 
tion through  the  parietes  of  the  abdomen,  in  which  no  jaundice 
had  at  any  time  appeared. 

When  gall-stones  are  small,  their  presence  probably  gives  rise 
to  few  or  no  symptoms.  But  when  they  are  large,  there  is  strong 
reason  to  believe  that  they  induce  symptoms  of  considerable  seve- 
rity. These  symptoms  may  be  of  two  sorts.  In  one  set  of  cases  they 
are  supposed  to  be  those  of  excruciating  pain,  and  that  of  a spasmodic 
character.  In  another  set  of  cases  they  induce  well-marked  symp- 
toms of  either  peritoneal  inflammation,  or  of  intestinal  obstruction, 
or  ileus,  or  of  both  combined. 

When  gall-stones  are  small  and  numerous,  and  are  contained  in 
the  gall-bladder,  they  cause  little  uneasiness ; and  numerous  ex- 
amples show  that  they  may  remain  in  that  situation  to  the  end  of  a 
long  life  without  giving  rise  to  prominent  symptoms. 

When,  on  the  other  hand,  they  are  large,  and  either  are  con- 
tained in  any  of  the  ducts  or  get  into  these  canals,  they  cause  very 
serious  evils.  Pain  in  the  epigastric  region,  often  of  an  excruciat- 
ing character,  relieved  only  by  incurvating  the  trunk,  vomiting, 
jaundice,  constipation,  are  all  effects  which  have  been  observed  to 
result  from  the  presence  of  gall-stones  in  the  ducts.  These  symp- 

* An  Account  of  an  unusually  large  Biliary  Calculus  voided  from  the  Rectum. 
By  James  A.  Wilson,  M.  D.  Med.-Chirurg.  Trans.,  vol.  xxvi.  p.  80.  London,  1843. 


GALL-STONES  AND  THEIR  EFFECTS. 


921 


toms  are  caused  either  by  the  presence  of  a large  distending  body 
in  the  ducts,  or  by  the  efforts  made  by  the  ducts  and  other  textures 
to  expel  that  body. 

When  gall-stones  are  unusually  large,  they  may  be  discharged 
either  by  vomiting  from  the  stomach ; or  by  the  intestinal  canal ; 
the  whole  of  which,  as  well  as  the  cystic  and  common  ducts,  they 
must  traverse ; or  they  procure  for  themselves  a route  to  the  sur- 
face of  the  body  by  means  of  ulceration,  most  commonly  through 
the  parietes  of  the  intestinal  canal  and  abdominal  muscles.  Indeed 
it  is  not  unlikely  that,  in  various  instances,  they  cause  ulceration 
through  the  hepatic  ducts  or  gall-bladder,  in  both  the  previous 
cases ; and  instances  are  recorded  in  which  ulceration  must  have 
been  previously  effected  in  the  gall-bladder  or  hepatic  and  cystic 
ducts,  before  the  gall-stone  could  get  either  into  the  intestinal 
canal,  or  come  to  the  surface. 

1.  It  is  not  very  usual  for  gall-stones  to  be  expelled  from  the 
stomach  by  vomiting.  Schurig,  nevertheless,  mentions  not  fewer 
than  eight  instances  in  which  gall-stones  had  been  ejected  in  this 
manner.*  Orteschi  records  one  case  in  his  Diary.f  One  is  given 
in  the  Gazette  Salutaire ; and  one  is  given  by  Biondi.j; 

2.  Through  the  intestinal  canal  it  is  greatly  more  common  to  ob- 
serve gall-stones  expelled  ; and  while  numerous  cases  are  record- 
ed, many  must  have  taken  place  without  being  noticed.  The  fol- 
lowing are  the  best  authenticated. 

F.  Ruysch,  Thesaurus  Anatoraicus  Quintus,  n.  32. 

Dr  Musgrave  records  an  instance  of  an  oval  gall-stone  nearly 
one  inch  long,  and  weighing  59  grains,  being  voided  by  a gentleman, 
after  an  attack  of  jaundice,  with  much  pain  in  the  epigastric  region.§ 

Bezold  records  the  case  of  a woman  of  52,  who,  after  much  suf- 
fering, passed  a wedge-shaped  hard  biliary  concretion,  weighing, 
immediately  after  discharge,  one  ounce  two  drachms  and  half  a 
scruple,  which  measured  in  its  long  circumference  from  two  inches 
and  a half  to  three  inches  and  a half,  and  in  the  middle  was  about 
four  inches  and  a half.|| 

Mr  J,  Yonge,  in  a letter  to  Hooke,  informs  him  that  he  had 
lately  seen  a gentlewoman  almost  dead  in  jaundice  relieved  by  the 

* Lithologia.  f In  Diario,  p.  283.  t Giornale  di  Medicina,  i.  p.  282. 

§ A Letter  from  Dr  William  Musgrave  to  Dr  Hans  Sloane  concerning  Jaundice  oc- 
casioned by  a stone  obstructing  the  Ductus  Commvmis  Biliarius.  Phil.  Transact.  No. 
306,  p.  227.  London,  1706-1708. 

II  Georgii  Bezold  Dissertatio  de  Cholelitho.  Argentorati,  24th  May  1725.  Apud 
Haller,  Dissert.  Medico-Practicas,  Tom.  iii.  p.  605. 


922 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


evacuation  of  a gall-stone  as  large  as  a pullet’s  egg ; and  another 
from  a man  as  big  as  a nutmeg ; both  followed  with  a lask  (loose- 
ness) discharging  prodigious  quantities  of  choler.  * 

John  Baptist  Bianchi  relates  the  case  of  a lady  of  rank  who  had 
been  subject  to  periodical  jaundice  from  twelve  to  fifteen  days  at  a 
time  ; and  from  whom  a gall-stone  larger  than  a walnut  was  brought 
away  by  the  operation  of  a strong  purge,  f 

Dr  James  Johnstone  records  a case  in  which  a corpulent  old 
lady,  after  suffering  for  two  days  severe  pain  in  the  epigastric  re- 
gion with  vomiting,  voided  an  oblong  pyriform  biliary  concretion, 
about  one  inch  and  a quarter  long,  and  fully  one  inch  in  diameter, 
and  weighing  126  grains.  She  had  no  jaundice,  but  seven  hours 
of  most  excruciating  pain.j: 

Lavernet  relates  a case  in  which  a large  biliary  concretion 
weighing  three  drachms  was  voided. 

Petit  mentions  the  case  of  a lady  who  had  jaundice  with  colicky 
pains.  After  the  use  of  the  warm-bath  three  times,  she  discharged 
with  much  blood  a gall-stone,  rough  like  the  skin  of  the  shark, 
weighing  four  drachms  and  two  scruples,  and  measuring  two  inches 
and  a half  long,  one  inch  and  a half  in  diameter,  and  three  inches 
and  a half  in  circumference. (| 

Walter  mentions  shortly  the  case  of  a female  of  about  70  years 
who  voided  two  gall-stones,  weighing  together  two  drachms  two 
scruples  = 160  grains.  The  largest  was  oblong  spheroidal,  a little 
more  than  one  inch  long,  and  a little  less  than  one  inch  in  trans- 
verse diameter.lf 

M.  Gosse  records  in  a married  lady  during  pregnancy  the  escape 
of  two  concretions  of  a burnt  umber  colour,  which  had  been  origi- 
nally one,  at  an  interval  of  ten  hours,  weighing  together  about  four 
drachms  (3  gros,)  and  the  first  of  which  was  14  lines  long  and  23 
in  circumference.  She  suffered  much  previously  from  colic  pains ; 
but  had  no  jaundice.** 

* Philosophical  Experiments  and  Observations  of  the  late  Dr  Robert  Hooke,  F.  R.  S. 
&c.  published  by  Wilbam  Derham,  F.  R.  S.  London,  1726,  p.  79. 

+ Historia  Hepatica  Joannis  B.  Bianchi,  M.  D.  Tom.  i.  p.  189.  Genevae,  1725. 

An  account  of  two  extraordinary  Cases  of  Gall-stones.  By  James  Johnstone, 
M.  D.  of  Kidderminster.  Phil.  Trans,  vol.  1.  p.  543.  London,  1758  ; and  Medical 
Essays  and  Observations,  &c.  Evesham,  1795,  8vo,  p.  200. 

§ Jom-nal  de  Medecine  Continue,  vol.  xv.  p.  404. 

II  Traite  des  Maladies  Chirurgicales,  Tome  i.  p.  325.  Paris,  1774  and  1790. 

•H  Henkel’s  Neuen  Medizinische  und  Chirurgischen  Anmerkungen.  1769.  And  Wal- 
ter Anatomisches  Museum,  T.  112,  213.  Taf.  2. 

**  Observation  d’un  Calcul  Biliare  expulse  par  les  selles  ; par  M.  Gosse.  Jom-nal 
de  Medecine  et  Chirurgie,  &c.  T.  xxxiv.  p.  45.  Paris,  1770. 


GALL-STONES  AND  THEIR  EFFECTS. 


923 


M.  Brillouet  gives,  in  a lady  of  68,  a case  in  which,  after  colic 
pains,  vomiting,  and  constipation,  lasting  apparently  about  a month, 
there  was  voided  first  a gall-stone,  five  lines  long  and  eighteen  in 
circumference,  and  weighing  forty-three  grains ; and  fourteen  days 
after  a similar  concretion,  six  lines  long,  and  weighing  fifty  grains ; 
both  fragments  of  one  gall-stone  weighing  together  one  drachm 
thirty- three  grains.* * * § 

Dr  Lettsom  records  the  case  of  a military  gentleman  of  Jamaica, 
who  had  laboured  for  years  under  severe  pain  of  the  epigastric  re- 
gion, which  was  ascribed  to  gout.  As  he  had  intervals  of  ease  for 
eight  or  ten  days.  Dr  Lettsom  suggested  that  his  complaints  de- 
pended on  the  presence  of  gall-stones.  At  length,  in  one  of  the 
fits,  he  voided  an  oblong  spheroidal  concretion  2 inches  long,  with 
a contraction  or  collar  in  the  middle,  weighing  1 ounce  2 drachms 
and  23  grains.  No  jaundice  took  place  in  this  case.f 

F.  G.  in  Meyer  Epist.  ad  Zimmermannum  Hannoverae,  1789, 
Editio  secunda,  1790. 

John  Gottlieb  Walter  notices  the  case  of  a man  of  71  who  voided 
an  oblong  spheroidal  gall-stone,  weighing  two  drachms,  two  scruples, 
ten  grains  =170  grains,  about  one  inch  and  a half  in  the  greatest 
diameter,  and  nearly  one  inch  in  the  small  diameter.  The  patient 
suffered  violent  spasmodic  pains  in  the  abdomen  ; but  all  ceased  on 
the  discharge  of  the  concretion,  j; 

Heberden  mentions  a case,  in  which  a female,  who  had  suffered 
from  jaundice  for  many  years,  at  length  voided  a concretion,  of 
which  the  smaller  circumference  was  two  inches.  § 

Mr  H.  L.  Thomas  records  in  a woman  of  63  an  instance  of  a 
globular  gall-stone  being  evacuated,  1.6  inch  largest  diameter,  1,1 
inch  small  diameter,  weighing  228  grains.  || 

Mr  T.  Brayne  records  in  a woman  of  55  an  instance  of  a gall- 
stone of  the  shape  of  a pigeon's  egg  being  expelled  from  the 
bowels,  measuring  If  greatest  diameter,  1|  shortest  diameter,  and 

* Observation  sur  un  Calcul  Biliare  expulse  par  les  selles,  par  M.  Brillouet.  Jour- 
nal de  Medecine,  T.  xxxvi.  p.  233.  Paris,  1771. 

f Case  of  a Biliary  Calculus.  By  J.  C.  Lettsom,  M.  D.  Read  4th  September  1786. 
Memoirs  of  Medical  Society,  Vol.  i.  art.  xxx.  p.  373.  London,  1787. 

t Anatomisches  Museum  Gesammelt  von  Johann  Gottlieb  Walter,  S.  96,  Taf.  iv. 
Berlin,  1796.  4to. 

§ Commentarii  de  Morborum  Historia  et  Curatione.  Lond.  1797.  8vo.  Cap.  50, p.  209. 
II  Case  of  Obstruction  of  the  Large  Intestines  occasioned  by  a Biliary  Calculus  of 
extraordinary  size.  By  H.  L.  Thomas,  Esq.  Medico-Chinu-g.  Transactions,  vol.  vi, 
p.  99.  London,  1815. 


924 


GENERAL  AND  PATHOLOGICAL  ANATOMY, 


weighing  162  grains.  Occasional  slight  jaundice.  Symptoms  of 
ileus.* 

The  same  gentleman  records,  in  a female  of  65,  an  instance 
in  which,  after  much  suffering,  a flat  cubical  concretion,  with 
rounded  angles  and  concave  depressed  sides,  weighing  176  grains, 
and  one  inch  in  diameter,  was  voided ; and  another,  six  days  after, 
hemispherical  in  shape,  and  159  grains,  was  expelled.  ^No  jaundice. 

I met,  in  March  1824,  with  a case  in  an  elderly  lady,  who,  after 
being  very  ill  for  eight  days  with  symptoms  of  obstinate  ileus,  voided 
a large  spherical  biliary  concretion,  weighing,  when  dried,  160 
grains,  and  measuring  one  inch  two  lines  in  diameter.  In  this  case 
no  yellowness  ever  was  observed.! 

Dr  Robert  Paterson  of  Leith  presented  to  me,  in  1842,  the  half 
of  a spherical  gall-stone,  fully  one  inch  in  diameter,  which  had 
been  voided  some  time  previously  by  a patient  of  his,  after  pre- 
senting symptoms  of  obstinate  obstruction,  without  jaundice. 

Dr  James  Arthur  Wilson  records  a case  in  which  a gentleman 
of  73,  after  suffering  from  constipation,  with  jaundice  and  hiccup, 
and  vomiting  for  many  days,  voided  a large  biliary  concretion,  con- 
sisting of  cholesterine  in  the  centre,  and  inspissated  bile  with  choles- 
terine  externally. ! 

The  question  has  often  occurred  to  my  mind  since  I witnessed 
the  violent  and  obstinate  symptoms  both  of  inflammation  and 
intestinal  obstruction,  with  which  the  case  now  referred  to  was 
attended,  whether  these  large  calculi  merely  distend  the  ducts 
before  getting  into  the  intestinal  canal,  or  pave  to  themselves  a 
passage  by  inflammation  and  ulceration.  It  appears  to  me  that 
though,  in  some  instances,  dilatation  of  the  ducts  may  take  place, 
and  be  sufficient  for  the  transport  of  the  concretion,  yet  in  several 
inflammation  and  ulceration  had  taken  place.  Though  I distinguish 
this  class  of  cases  from  those  which  are  to  come  next,  yet  we  must 
remember  that  nature  knows  no  distinction  of  this  kind.  When  a 
gall-stone  is  fixed  either  in  one  part  of  any  of  the  three  ducts,  or 
in  the  gall-bladder,  it  may  there  give  rise  to  inflammation  and  suppu- 
ration of  the  surrounding  textures ; and  it  will  depend  on  several 

* An  Account  of  two  Cases  of  Biliary  Calculi  of  extraordinary  Dimensions.  By 
T.  Brayne,  Esq.  Medico-Chirurg.  Transactions,  Vol.  xii.  p.  255.  London,  1823. 

4 History  of  a case  in  which  the  symptoms  of  Ihac  Passion  arose  fi'oni  the  transit  of 
an  unusually  large  gall-stone,  terminating  favourably.  By  David  Craigie,  M.  D.  Edin- 
burgh Medical  and  Surgical  Journal,  vol.  xxii.  p.  235.  Edinburgh,  1824, 

+ An  Account,  &c.  Medico-Chirurg.  Transactions,  vol.  xxvi.  London,  1843. 


GALL-STONES  AND  THEIR  EFFECTS. 


925 


circumstances  what  course  this  inflammation  is  to  take,  what  textures 
it  will  affect,  and  by  what  channel  the  concretion  will  finally  proceed. 
The  suppurative  process  may  then  be  either  confined  more  or  less 
strictly  to  the  tissues  immediately  concerned,  as  the  gall-bladder, 
the  cystic  duct,  the  hepatic  duct,  or  common  duct,  or  two  of  these 
at  once  according  to  the  position  of  the  concretion,  and  the  cellular 
substance  of  the  capsule  of  Griisson  and  the  duodenum ; or  it  may 
extend  to  a larger  portion  of  the  intestines,  and  even  by  ulceration 
and  adhesion  to  the  parietes  of  the  abdomen  themselves.  The 
latter  result  is  most  likely  to  happen  when  the  concretion  is  in  the 
gall-bladder,  fundus  or  base  of  which  is  very  near  the  abdomi- 
nal muscles.  Yet  there  is  no  assurance  that  the  same  course  may 
not  be  followed  when  the  concretion  is  in  the  cystic  or  common 
duct,  or  even  in  the  hepatic  duct.  In  the  first  case,  the  concretion 
is  discharged  into  the  cavity  of  the  intestines, — viz.  the  duode- 
num^ the  ileum,  or  the  transverse  arch  of  the  colon.  In  the  latter, 
it  is  almost  uniformly  expelled  by  an  ulcerated  opening  through 
the  abdominal  parietes. 

The  reason  which  induces  me  to  think  that  these  concretions  may 
pass  into  the  intestinal  canal  by  means  of  ulceration,  is  found  in 
such  cases  as  that  given  by  Tyson  of  an  abscess  in  the  liver,  in 
which  gall-stones  were  found  in  the  gall-bladder,  the  ductus  cysticus, 
common  duct  and  in  the  porus  hiliarius,  or  hepatic  duct  •,*  a case 
mentioned  by  Walter  (at  page  126),  in  which  he  infers  that  the 
gall-bladder  must  have  been  inflamed  and  suppurated,  forming 
around  it  a pouch  or  sac,  connected  with  the  transverse  arch  of  the 
colon  that  already  mentioned  at  page  867  of  this  work ; and  that 
given  by  Dr  Scott,  in  which  the  patient  died  during  inflammation 
of  the  gall-bladder,  caused  by  the  presence  of  a concretion  as  large 
as  an  olive ; and  which,  had  life  been  prolonged,  must  have  found 
its  way  by  ulceration  into  the  intestines  or  to  the  surface  of  the 
body,+ 

3.  The  latter  appears  to  be  the  mode  of  exit  most  common  in 

* Anatomical  observations  of  an  abscess  in  the  liver,  a great  number  of  stones  in 
the  gall-bag  and  bilious  vessels,  &c.,  by  Edward  Tyson,  A.  M.,  &c.  Oxon.  Phil. 
Trans.,  No.  142,  p.  1035.  London,  1678,  voL  xi. 

•f-  Anatomisches  Museum  Gesammelt  von  Johan  Gottlieb  Walter.  Berlin,  1796, 
4to. 

+ Case  of  Death  from  Inflammation  of  the  Gall-bladder,  occasioned  by  the  irrita- 
tion of  a Stone.  By  Da^dd  Scott,  M.  D.  Edin.  Med.  and  Surg.  Journal,  Vol,  xxiii. 
p.  297.  Edin.  1825. 


926 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  case  of  large  concretions ; yet  it  is  not  confined  to  them,  but 
serves  as  the  channel  for  evacuation  of  moderate-sized  gall-stones 
also.  Of  this  mode  of  expulsion,  many  instances  are  recorded ; but 
I mention  only  the  following  in  illustration  of  the  circumstance. 

In  the  Ephemerides  Naturae  Curiosorum  cases  by  many  authors. 

Tolet  states  that  he  saw  a gall-stone  as  large  as  a pigeon’s  egg 
discharged  by  an  ulcer  at  the  navel.* * * § 

The  editor  of  the  Bologna  Commentaries  gives,  from  the  prac- 
tice of  Tacconi,  in  1739,  the  following  case.  A married  woman 
of  27  suffered  for  some  time  under  pain  at  the  epigastric  region, 
squeamishness,  occasional  vomiting,  and  at  length  a suppurating 
swelling  near  the  site  of  the  right  lobe  of  the  liver.  Into  this  an 
incision  was  made  ; when  four  ounces  of  matter  and  seven  biliary 
concretions  came  away.  In  the  course  of  fourteen  days,  other  con- 
cretions came  away,  varying  in  shape,  size,  and  weight,  one  as  large 
as  a nutmeg.  After  this,  recovery  took  place.  No  jaundice  was 
observed.! 

Cheselden  mentions  a case  in  which  two  gall-stones,  six  lines  in 
diameter,  were  discharged  through  the  abdominal  integuments-! 

Hoffmann  mentions  a case  in  which  eighty  gall-stones  were  dis- 
charged by  an  ulcer  in  the  abdomen.  § 

Wislicen  records  the  case  of  a man  who,  after  suffering  for  one 
year  much  pain  in  the  abdomen,  had  a tumour  in  the  right  groin, 
which  was  opened  by  caustic,  and  discharged  at  length  upwards  of 
fifty  concretions  of  the  size  of  beans  and  peas-H 

Petit  mentions  three  instances.  The  first  was  that  of  a lady  who 
had  a pointing  tumour  in  the  right  hypochondre,  which,  on  being 
opened,  discharged  at  first  pure  bile ; and  from  which,  seven  or 
eight  months  afterwards,  there  escaped  a gall- stone. IF  The  second 
one,  from  Lapeyronie,  in  a woman  of  37,  in  whom  a tumour  ap- 
peared in  the  epigastric  region,  which,  on  being  opened,  discharged 
purulent  matter  with  bile,  and  five  or  six  concretions  of  the  size  of 

* Traite  de  la  Lithotomie.  8 vo,  4trieme  edition,  Utrecht.  Chap.  iv.  p.  24.  1693. 

+ De  Bononiensi  Scientiarum  et  Artium  Institute  atque  Academia  Commentarii,  T. 
2di,  Pars  prima.  Bononiae,  1745.  4to,  p.  212. 

^ Anatomy,  Book  iii.  chap.  v.  p.  166.  12th  edit.  London,  1784. 

§ Crell  Chemische  Annalen  1789.  viii.  St.  Seite  128. 

II  J.  Andreae  Wislicen  Lapides  per  Abdomen  ulceratione  exclusi.  Lipsiae,  1742. 
Apud  Haller  Dissertationes  Medico-Practicas,  T.  iii.  p.  629. 

^ Traite  des  Maladies  Chirurgicales,  Oeuvrage  Posthume  de  J.  L.  Petit.  Tome  i.  p. 
313.  Mis  au  jour,  par  M.  Lesne.  Paris,  1790. 

4 


GALL-STONES  ESCAPING  BY  ULCERATION. 


927 


peas.* * * §  In  a third,  a female  of  74,  he  extracted  from  a fistulous 
opening  in  the  right  hypochondre  first  one  concretion  four  inches 
long  and  three  in  circumference,  and  afterwards  another  smaller 
concretion. 

A case  in  the  Commerdum  Norimberg.  1743,  p.  81. 

Dr  James  Johnstone  mentions  the  case  of  a woman  of  upwards 
of  30  labouring,  in  1752,  under  jaundice  and  excruciating  pain, 
striking  from  the  right  hypochondre  to  the  back,  with  frequent  fits 
of  vomiting.  At  this  time,  hardness  was  felt  at  the  pit  of  the  sto- 
mach. About  three  months  after  this  time,  the  tumour  suppurated, 
and  discharged  with  matter  several  gall-stones.  She  recovered, 
and  died  in  1763.f 

M.  Marechal  and  Guerin,  in  attending  a lady  of  rank,  who  had 
a suppurating  tumour  at  the  margin  of  the  right  hypochondre, 
opened  it  by  incision,  and  removed  a gall-stone  as  large  as  the 
largest  acorn,  j; 

Haller  mentions  the  instance  of  a woman  in  whom,  from  an  ulcer 
in  the  epigastric  region,  several  biliary  calculi  were  discharged,  an- 
gular, trihedral ; the  patient  surviving.  § 

Bloch  saw  several  concretions  come  away  from  an  ulcer  under 
the  false  ribs  ;1|  and  Buttner  saw  thirty-eight  gall-stones  discharged 
from  an  aperture  near  the  navel.1T 

Civadier  saw  several  gall-stones  come  away  from  an  ulcer  in  the 
right  groin.** * * §§ 

Acrell  published  in  1788  atUpsal  a dissertation  on  gall-stones 
escaping  by  ulceration  through  the  abdominal  parietes ; and  Sand- 
torff  published  at  Helmstadtlf  a dissertation  on  the  same  subject, 
containing  accounts  of  various  cases.  Vogler  gives  an  instance  of 
the  occurrence  and  Bruckmann  observed  several  gall-stones 
escape  successively  through  an  abscess  in  the  abdomen.  §§ 

* Lapeyronie,  Memoires  de  I’Academie  de  la  Chirurgie,  T.  i.  p.  185.  Paris,  1743  ; 
and  Petit,  Oeuvres  Posthumes,  Tome  i.  p.  320  and  325.  Paris,  1774  and  1790. 

t Philosophical  Transactions,  Vol.  1.  p.  543,  and  Essays,  p.  207. 

t Observations  par  M.  Morand,  Memoires  de  I’Academie  Royale  de  Chirurgie, 
Tome  ui.  p.  470.  Paris,  1757. 

§ Opuscula  Pathologica,  Lausannae,  1767  et  1768.  Ohs.  38,  Hist.  8. 

II  Medicinische  Bemerkungen.  Berlin,  1774. 

^ Funf  Besondere  Wahmehmungen.  Koenigsberg,  1774. 

**  Nouvelles  Economiques  et  Litteraires,  Tom.  xx. 

•)"t"  Hissertatio  de  Cholelithis  ex  ulcere  abdominis  elapsis.  Helmstadii,  1810. 

Museum  der  Heilkunde,  iv.  Band,  p.  91. 

§§  Horn’s  Archiv,  1810,  p.  231,  144. 


928 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Mr  George  White,  formerly  a practitioner  in  this  city,  Informed 
me,  in  May  1825,  some  time  after  I had  published  the  account  of 
the  large  gall-stone  voided,  as  already  mentioned,  from  the  bowels, 
of  an  instance  in  which  first  inflammation,  and  suppuration,  and 
then  ulceration  of  the  abdominal  parietes  took  place,  and  through 
the  aperture  thus  made  a gall-stone  of  considerable  size  was  dis. 
charged,  with  recovery  of  the  patient. 

I may  add  also,  that,  in  the  Museum  of  Guy’s  Hospital,  there 
are  preserved  two  biliary  concretions,  which  made  their  escape 
through  an  abscess  at  the  navel  in  a female  patient  of  Mr  T.  Cal- 
loway, one  of  the  surgeons  to  that  institution. 

Dr  Macnish  gives  an  interesting  case,  in  which,  some  months  af- 
ter an  attack  of  acute  hepatitis,  an  abscess  was  formed  below  the 
margin  of  the  ribs,  which  was  at  length  laid  open  by  incision.  About 
twenty-five  days  after  this,  a gall-stone  as  large  as  a nutmeg  was 
discharged  from  the  wound ; and  four  days  after  another  concre- 
tion and  some  fragments  were  discharged.  A good  deal  of  bile 
was  afterwards  mixed  with  the  discharge.  But  the  patient  made  a 
good  recovery,  the  wound  having  completely  cicatrized  about  twelve 
months  after  the  date  of  incision.* 

In  short,  there  is  no  lack  of  evidence  to  show,  that  biliary  con- 
cretions of  all  sizes  may  find  their  way  to  the  surface  of  the  body 
by  a process  of  progressive  inflammation  and  suppuration,  the  parts 
behind  and  around  being  united  by  the  eflPusion  of  lymph,  so  as  to 
prevent  the  concretion  from  getting  into  the  peritoneum.  It  is, 
indeed,  important  to  observe,  that  while  numerous  cases  of  this 
mode  of  exit  are  recorded,  in  all  of  which  the  movement  of  the  con- 
cretion must  have  been  attended  with  ulceration,  and  not  less  nu- 
merous cases  of  their  transit  into  the  intestinal  canal,  in  several  of 
which,  probably,  the  same  process  took  place,  no  instance  is  recorded 
of  a gall-stone  dropping  into  the  cavity  of  the  peritoneum,  except 
in  one  doubtful  instance,  f 

After  the  foregoing  detail,  it  is  superfluous  to  say  that  the  gall- 
bladder and  biliary  ducts  are  liable  to  be  afiected  by  inflammation 
and  ulceration.  The  ducts  are  liable  to  become  obliterated  in  the 
course  of  the  process. 

* Case  of  Tumour  in  the  Region  of  the  Liver,  with  discharge  of  Biliary  Calculi 
through  the  abdominal  parietes.  By  William  Macnish,  M.D.  &c.  Edinburgh  Me- 
dical and  Surgical  Journal,  Vol.  xli.  p.  169.  1834. 

+ Andree, 


3 


INFLAMIATION  OF  THE  KIDNEY. 


929 


One  cause  of  tumour  and  eventually  abscess  has  been  pointed 
out  by  Petit  in  France,  and  Amyand  in  this  country.  This  con- 
sists in  an  accumulation  of  bile,  too  thick  apparently  to  flow  through 
the  duct,  attended  probably  with  some  obstruction  either  in  the 
cystic  or  common  duct,  by  which  the  bile  is  prevented  from  getting 
into  the  duodenum,  and  consequently  distends  the  gall-bladder, 
which  then  is  inflamed. 

§ 4.  The  gall-bladder  is  liable  to  be  involved  in  the  heterolo- 
gous deposits  by  which  the  liver  is  affected. 

§ 5.  The  gall-bladder  has  been  found  altogether  wanting  by  Mar- 
cellus  Donatus,  Schenke,  Huber,f  Targioni  Tozzetti,|  Sandifort,§ 
and  Wiedemann.  II 

§ 6.  It  is  liable  to  be  ruptured,  to  be  wounded  or  lacerated,  and 
to  be  ossified. 

Section  V. 

Morbid  States  of  tue  Kidney. 

The  kidney  is  liable  to  be  the  seat  of  inflammation  of  various 
sorts,  and  its  effects,  especially  suppuration  within  the  calyces ; to 
the  formation  and  presence  of  calculi  within  the  calyces  and  pelvis  ; 
to  enlargement  and  dilatation,  and  hemorrhage ; to  granular  dege- 
neration {steatosis) ; to  the  formation  of  serous  cysts ; to  atrophy ; 
to  hypertrophy ; and  to  the  heterologous  growths. 

§ 1.  Nephritis.  Inflammation  and  its  Effects. — The  kid- 
ney is,  like  other  glands,  liable  to  inflammation ; but  this  is  more 
particularly  the  consequence  of  certain  circumstances  residing  either 
in  the  general  system  of  the  individual ; or  in  the  organ  itself ; or 
in  the  relation  of  the  organ  to  the  stomach,  and  the  function  of 
digestion  and  assimilation.  It  is  said  that  idiopathic  inflammation 
of  the  kidney  is  a rare  affection ; and  that  most  commonly  the  dis- 
ease is  symptomatic,  that  is,  is  supposed  to  indicate  the  presence 
and  operation  of  some  irritant  agent.  This  may  he  correct  as  to 
acute  attacks ; but  it  is  not  applicable  to  chronic  affections,  which 
come  on  and  are  established  either  without  perceptible  cause,  or 
depend  on  the  state  of  the  blood  and  of  the  organs  of  digestion. 
The  idiopathic  form  is  liable  to  take  place  in  the  gouty,  as  a symp- 
tom of  the  gouty  diathesis  aud  internal  gout,  being  one  form  in 

* Philosoph.  Transact.  492.  T Journal  de  Medecine,  Tome  iv.  p.  283. 

J Tabulae  Anatomicae,  Fasciculus  iiL 

§ Reil  Archiv  fiu:  die  Physiologic,  v.  Band,  p.  145. 

3 N 


980 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


which  gout  affects  the  kidney  ; and  it  is  known  by  the  individual 
having  presented  more  or  fewer  of  the  symptoms  of  gout,  and  by 
the  disease  terminating  in  or  being  associated  with  a paroxysm  of 
regular  gout. 

Renal  inflammation  may  ensue  on  blows  or  contusions  on  the 
loins;  falls  in  which  the  kidney,  with  other  organs,  suffers  concus- 
sion ; carrying  heavy  loads  on  the  back,  or  wrenches  in  conse- 
quence of  falling  in  cari’ying  loads ; riding  on  horseback ; riding 
in  a carriage  over  a rough  road ; the  presence  of  renal  concretions 
or  sabulous  matter  in  the  infundibula  or  pelvis,  especially  if  the 
former  be  rough,  or  angular;  various  irritants  taken  into  the 
stomach,  which  either  induce  acidity,  or  being  absorbed  by  the 
blood-vessels,  are  enabled  to  irritate  the  tissue  of  the  kidney,  as 
some  of  the  vegetable  acids  and  fruits,  acid  wines ; the  application 
of  cantharides  externally,  or  their  use  internally ; the  terebinthinate, 
resinous,  and  balsamic  substances ; cold  applied  to  the  lumbar  re- 
gion, especially  when  overheated ; inflammation  of  the  adjoining  or- 
gans, as  the  liver,  spleen,  duodenum,  colon,  psoas  muscle,  the  dor- 
sal or  lumbar  vertebrae ; and  in  some  instances  inflammation  of  the 
bladder,  extending  upwards  through  the  ureters,  either  resulting 
from  excessive  distension  of  these  organs,  or  without  distension. 

Of  the  whole  of  these  circumstances  which  may  be  regarded  as 
exciting  causes,  the  operation  is  very  much  favoured  by  the  presence 
of  the  gouty  or  calculous  diathesis  already  mentioned. 

Inflammation  may  attack  either  the  pelvic  and  calycine  membrane 
of  the  kidney ; or  the  substance  of  the  gland ; or  the  external  sur- 
face of  the  gland,  with  or  without  its  investing  membrane. 

The  most  common  is  inflammation  of  the  calycine  membrane,  or 
that  part  of  the  mucous  epithelial  membrane  of  the  kidney,  which 
extends  upwards  from  the  pelvis  into  the  calyces  and  papilloe.  This 
membrane  is  then  injected  into  blood,  covered  by  a coating  of 
lymph  more  or  less  thick,  and  the  free  surface  of  which  is  formed 
into  a multitude  of  minute  ]>rocesses  or  scales,  while  purulent  mat- 
ter is  eventually  deposited  within  this.  The  subsequent  course  of 
this  process  shall  be  noticed  presently. 

When  the  substance  of  the  kidney  is  inflamed,  it  becomes  of  a 
deep  red  or  reddish  brown  colour,  abounds  in  blood-vessels,  much 
loaded  with  blood ; the  whole  organ  is  enlarged  in  all  its  dimen- 
sions ; and  its  substance  is  copiously  infiltrated  with  bloody  serum. 
As  to  consistence,  nothing  is  certain ; the  inflamed  kidney  being 

3 


INFLAMMATION  OF  THE  KIDNEY. 


931 


sometimes  softer  than  natural,  sometimes  harder.  This  difference 
depends  prohahly  on  the  duration  of  the  inflammatory  process. 
Blood  may  be  expressed  from  the  papillae.  In  some  instances  small 
points  and  drops  of  purulent  matter,  or  purulent  matter  and  fluid 
lymph,  are  infiltrated  into  the  substance  of  the  gland. 

The  terminations  vary  according  to  the  causes  on  which  the 
disease  depends,  the  method  of  treatment,  and  the  nature  of  the 
affection. 

Idiopathic  renal  inflammation  may  terminate  in  resolution,  in  an 
attack  of  gout,  in  the  deposition  of  sand  or  sabulous  concretions 
(lithiasis),  in  suppuration,  in  suppuration  with  extenuation  of  the 
kidney,  in  induration  or  softening  of  the  kidney,  and  perhaps  in 
granular  deposition  and  transformation,  or  in  death. 

Idiopathic  nephritis  may,  under  the  prompt  use  of  remedies,  ter- 
minate in  resolution  on  the  third,  fifth,  or  seventh  day.  In  this  case 
the  pain  gradually  or  speedily  abates  and  finally  disappears ; the 
vomiting  ceases,  the  heat  and  thirst  are  diminished,  the  patient  be- 
comes less  restless,  and  at  length  falls  asleep ; and  the  skin  becoming 
moist,  he  awakes  in  general  without  any  feeling  of  his  former  suf- 
ferings, with  the  pulse  down  at  80  or  even  lower,  and  begins  to  dis- 
charge without  pain  or  uneasiness  a considerable  quantity  of  urine, 
usually  dark-coloured,  like  brown  dirty  water  or  coffee,  which  de- 
posits on  cooling  a sediment  dark-coloured,  and  sometimes  slightly 
bloody.  In  the  course  of  a day  or  two,  if  this  amendment  con- 
tinue, the  urine  returns  to  its  natural  standard  in  quantity,  quality, 
and  appearance. 

In  cases  of  gouty  diathesis,  the  pain  of  the  renal  region  subsides 
or  disappears,  and  at  the  same  time  pain,  redness,  and  swelling 
appear  on  the  foot  or  hand,  and  pass  through  their  usual  course. 

If  neither  of  these  results  take  place  on  or  before  the  fifth  or 
the  seventh  day,  it  may  be  apprehended  that  the  disease  is  to  ter- 
minate either  fatally,  or  in  suppuration  or  abscess,  or  distension 
and  attenuation  of  the  kidney,  or  one  or  other  of  the  events  already- 
specified. 

When  the  fatal  termination  takes  place,  it  is  generally  preceded 
by  complete  suppression  of  the  urinary  secretion,  slow  full  pulse, 
stupor  proceeding  to  coma,  and  a urinous  exhalation  from  the  sur- 
face of  the  body. 

When  nephritis  terminates  neither  in  resolution  nor  in  death,  it 
may  he  apprehended  that  it  is  to  end  in  suppuration  or  some 


932 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


similar  disorganizing  process  in  the  kidney  ; and  though  this  may 
take  place  in  the  spontaneous  or  idiopathic  form  of  the  disorder, 
it  is  much  more  likely  to  ensue  in  cases  in  which  the  disease  is  in- 
duced by  the  mechanical  irritation  of  an  urinary  concretion. 

It  is  requisite  here,  therefore,  to  specify  the  circumstances  under 
which  suppuration  is  most  likely  to  take  place,  and  the  usual  forms 
under  which  it  appears. 

§ 2.  Though  suppuration  of  the  kidney  may  take  place  either  in 
its  cortical  or  secreting  part,  or  in  its  tubular  or  excreting  portion, 
yet,  so  far  as  the  evidence  of  morbid  anatomy  goes,  the  most  usual 
mode  in  which  suppuration,  or  rather  the  secretion  of  purulent 
matter  takes  place,  is  the  following. 

1.  An  attack  of  renal  inflammation  may,  if  it  affect  mostly  the 
tubular  part  of  the  kidney  and  the  infundibula,  terminate  in  the 
secretion  of  puriform  mucus,  plastic  lymph  and  blood  from  the 
calycine  membrane,  that  is  the  delicate  mucous  surface  of  these 
cavities,  and  the  •papilla,  and  from  the  mucous  surface  of  the  pelvis  ; 
and  these  morbid  secretions  may  either  escape  through  the  ureter 
into  the  bladder,  and  be  expelled,  or  they  may  remain  and  produce 
obstruction  of  the  pelvis,  secondary  inflammation,  and  distension 
of  the  pelvis  and  infundibula. 

In  the  former  case,  the  matter  escapes  by  the  ureters  into 
the  bladder,  partially  or  entirely,  and  is  discharged  in  the 
form  of  purulent  matter,  mixed  with  urine  or  purulent  urine 
{pyuria) ; but  it  is  liable  again  to  accumulate,  unless  the  in- 
flammatory action  is  totally  subdued.  If  it  do  accumulate,  it 
then  becomes,  in  all  respects,  similar  to  the  latter  case,  and 
a peculiar  state  of  the  kidney  is  presented,  (Nephrotasia  ; Ne- 
phropyema).  The  matter  retained  within  the  pelvis  and  infun- 
dibula, or  at  least  not  permitted  to  escape  by  tbe  ureter,  either 
mixed  with  urine,  or  by  itself,  gradually  accumulates  and  increases 
in  quantity,  and  causes  more  or  less  distension  of  the  pelvis  and 
infundibula.  If  this  be  moderate,  and  if  death  take  place,  the 
kidney,  when  divided,  presents  as  many  cavities  containing  puru- 
lent matter  as  there  are  infundibula ; and  while  the  substance  of 
the  kidney  is  rendered  much  thinner  than  usual,  these  cavities  are 
sometimes  supposed  to  be  purulent  cysts  into  which  the  kidney  has 
been  con  verted.  This  is  the  true  explanation  of  such  cases  as  that 
mentioned  by  Cbeston,  who  states  that  in  a boy  of  seven,  “ the 
substance  of  the  kidneys  was  so  dissolved  into  matter,  that  they  ap- 


THE  KIDNEYS NEPHROPYEMA. 


933 


peared  little  more  than  cysts  full  of  pus,  the  one  weighing  four 
ounces  and  the  other  three.”*  I have  seen  several  cases  in  which 
observers  otherwise  able  were  deceived  by  his  appearance,  and  were 
led  to  imagine  that  the  kidney  was  converted  into  purulent  cysts. 
The  mistake  is  rectified  by  removing  the  purulent  matter  cauti- 
ously, and  washing  the  cavities  in  pure  water,  when  it  is  observed 
that  the  fine  membrane  covering  the  papillce  and  lining  the  infun- 
dibula (membrana  calycina)  is  a little  rough  and  thickened,  very 
generally  covered  with  lymph,  but  not  destroyed  or  marked  by  any 
breach  of  continuity ; that  the  papillse  may  be  recognized  also  en- 
tire ; and  that  the  only  change  which  has  taken  place  is  consider- 
able distension  by  purulent  matter,  and  consequent  attenuation  of 
the  tubular  and  cortical  part  of  the  kidney. 

The  quantity  of  matter  accumulated,  however,  may  be  consider- 
able, the  distension  great,  and  the  consequent  attenuation  of  the 
renal  substance  may  be  carried  to  a great  extreme.  The  first  eflTect 
of  this  increased  accumulation  is,  by  the  distension,  to  force  two  or 
more  infundibula,  into  one  common  and  considerable  cavity  or  sac ; 
the  next  eflFect  is  gradually  to  force  several  infundibula  into  one 
considerable  sac ; and  if  the  accumulation  continue  and  the  disten- 
sion proceed,  the  infundibula  and  pelvis  are  converted  into  one 
general  extensive  sac,  containing  purulent  matter.  In  cases  of 
this  description,  the  cortical  and  tubular  substance  of  the  kidney 
are  so  much  stretched  and  attenuated,  that  not  unfrequently  they 
are  not  thicker  than  a crown  or  a half-crown  piece ; and  it  might 
be  imagined  that  these  tissues  were  almost  or  altogether  destroyed 
by  suppuration,  and  that  nothing  is  left  but  the  external  capsule. 
When,  however,  a proper  section  is  made,  the  purulent  matter 
evacuated,  and  the  parts  washed  with  pure  water,  the  calycine 
membrane  and  the  papillm  may  be  recognized, — the  former  rough 
with  lymph  and  thickened  mucus,  the  latter  much  compressed ; the 
individual  tubular  cones  may  be  traced,  though  much  stretched  and 
separated ; and  the  cortical  structure  may  be  perceived  in  the  form 
of  a thin  exterior  coating. 

The  size  which  the  expanded  and  attenuated  kidney  may  in  these 
circumstances  attain,  is  often  very  great,  and  the  quantity  of  mat- 
ter with  or  without  urine  very  considerable.  The  older  authors, 
as  Blasius  and  Ott,  have  not  distinguished  the  disease  with  accu- 
racy or  precision  ; and  consequently  I can  make  little  use  of  these 


Pathological  Inquiries,  Chap.  ii.  p.  9.  Gloucester,  1766. 


934 


GENERAL  AND  rATlIOLOGICAL  ANATOMY. 


cases.  But  the  kidney  has  been  in  this  state  found  to  be  as  large 
as  the  head  of  a child,  and  to  contain  almost  two  pounds  or  more 
of  purulent,  sero-purulent,  or  urino-purulent  fluid ; and  in  one 
case  which  was  known  to  me,  the  left  kidney  was  so  much  enlarged 
and  distended,  that  it  occupied  the  whole  left  side  of  the  abdomen 
and  extended  into  the  pelvis.  An  excellent  case  is  given  by  Cor- 
visart  in  his  journal.* 

This  disease  has  been  described  by  Frederic  Augustus  Walter 
in  one  stage,  under  the  name  of  expansion  of  the  kidneys,  {expan- 
sio  renum,)  and  in  another  under  the  title  of  dropsy  of  the  kidneys, 
(Nierenwasserseuche,)  {hydrops  renalis.')]  Neither  of  these  names 
are  appropriate ; and  the  latter  is  particularly  improper,  in  so  far 
as  it  conveys  a just  idea  neither  of  the  origin  of  the  disorder,  nor 
its  nature,  and  is  liable,  in  the  present  state  •of  pathological  know- 
ledge, to  be  confounded  with  the  secondary  dropsical  efiusions  which 
take  place  in  consequence  of  granular  degeneration  of  the  kidney. 
The  expansion  is  the  efibct  of  inflammation,  which,  by  giving  rise 
to  morbid  products,  causes  distension  of  the  kidney,  and  dilatation 
of  its  infundibula  and  pelvis,  much  as  sero-purulent  fluid  within  the 
pleura  separates  the  lungs  from  the  pleura  costalis  and  ribs,  and 
extrudes  the  walls  of  the  chest.  The  sero-purulent,  purulent,  or 
urino-purulent  fluid  contained  within  the  expanded  infundibula  and 
pelvis  of  the  kidney,  constitutes  no  resemblance  or  analogy  between 
the  fluid  and  those  of  dropsical  effusions ; and  the  name  should 
therefore  be  discarded.  If  a particular  denomination  be  wished 
for  the  disease,  the  terra  Nephropyema  or  Pyonephria  is  the  proper 
one,  and  the  term  Nephrotasia  may  be  used  to  signify  the  disten- 
sion. It  may  be  observed,  however,  that  the  latter  is  a mere  efiect 
of  the  accumulation  of  purulent  fluid. 

I think  that  Mr  Howship  has  been  misled  by  the  same  circum- 
stance, when,  in  speaking  of  this  change  under  the  head  of  disten- 
sion of  the  kidneys,  he  observes,  that  “ by  this  means  a degree  of 
pressure  is  established,  which,  as  it  increases,  induces  by  degrees  a 
total  resolution  of  the  whole  of  the  natural  structure  of  the  gland, 
which  is  ultimately  found  converted  into  an  assemblage  of  large 
and  small  cysts,  or  thin  membranous  capsules.”| 

* Journal  de  Medecine,  Tom.  vii.  p.  387. 

•j*  Einige  Krankheiten  der  Nieren  und  Harnblase.  Berlin,  1800.  4to. 

J A Practical  Treatise  on  the  Symptoms,  Causes,  Discrimination,  and  Treatment  of 
some  of  the  most  important  Complaints  that  affect  the  Secretion  and  Excretion  of  the 
Urine,  &c.  By  John  Howship,  Member  of  the  R.  C.  of  Surgeons  in  London.  Lon- 
don, 1823.  Section  vi.  p.  13. 


SUPPURATION  OF  THE  KIDNEY. 


935 


That  the  great  distension  which  in  some  cases  takes  place  may 
be  suflficient  to  separate  and  detach  forcibly  from  each  the  indivi- 
dual component  cones  of  the  kidney,  is  a circumstance  which  1 will 
not  deny.  But  I must  say  that  everything  known  regarding  the 
effect  of  suppuration  in  this  part  of  the  kidney  shows,  that  this  is 
not  a common  result ; and  that  the  most  frequent  consequence  by 
far  is  that  which  I have  here  represented  it  to  be.  It  is  quite  im- 
possible to  imagine  the  great  changes  produced  by  mere  pressure 
and  distension  in  the  human  body,  without  absolute  destruction  of 
the  organization  of  parts,  were  it  not  the  subject  of  daily  observa- 
tion, aided  by  accurate  inspection  of  the  state  of  the  parts. 

In  some  instances  this  purulent  distension  is  confined  to  one  or 
two  infundibula,  which  do  not  readily  communicate  with  the  others ; 
and  in  consequence  the  purulent  matter  contained  within  them 
does  not  escape  into  the  other,  but,  being  incessantly  increased, 
causes  expansion  and  enlargement  at  one  part  of  the  gland.  In 
other  cases  it  is  confined  to  the  pelvis,  and  produces  on  that  the 
same  effect  which  it  would  elsewhere,  but  leaving  the  kidney  for 
some  time  comparatively  uninjured. 

The  fluid  contained  may  be  purulent,  sero-purulent,  or  sero- 
purulent  mixed  with  urine,  that  is  urino-purulent.  In  some  of  the 
cases  described  by  Walter,  the  fluid  is  represented  to  have  been 
clear  and  diaphanous. 

It  is  proper,  however,  to  say,  that  Walter,  who  had  seen  several 
examples  of  this  disorder  from  obstruction  of  the  ureter  by  con- 
cretions, represents  the  whole  kidney  as  so  changed,  that  nothing 
seemed  to  be  left  except  the  exterior  membrane  or  capsule,  which 
was  so  much  extenuated  by  the  pressure  of  the  contained  fluid, 
that  the  part  which  was  previously  a kidney,  presented  the  appear- 
ance of  an  expanded  bladder.  This  distension  he  ascribes  solely  to 
the  accumulation  of  urine,  which,  not  being  allowed  to  pass  by  the 
ureter,  stagnates  in  the  pelvis  and  infundibula^  and  by  compression 
upon  their  excreting  and  secreting  parts  and  vessels,  first  impedes 
and  then  suspends  the  secretion  and  excretion  of  the  gland. 

In  instances  of  great  distension  he  mentions,  that  not  only  is  all 
the  perinephral  fat  absorbed,  but  the  exterior  membrane  itself  may 
be  transformed  into  an  osseous  capsule,  as  was  exemplified  in  various 
preparations  preserved  in  the  collection  of  his  father.  The  de- 
scription now  mentioned  is  most  applicable  to  that  obstruction  which 
arises  from  the  presence  of  a concretion  in  the  pelvis  or  ureter. 


936 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


§ 3.  Nephropsammia  ; Lithiasis  Nephritica. — An  attack  of 
renal  inflammation  may  terminate  in  the  secretion  of  a considerable 
quantity  of  sabulous  matter,  with  or  without  puriform  or  morbid 
mucus  and  blood ; and  if  this  escape  not  by  the  ureter  into  the 
bladder,  and  be  thence  expelled  in  the  usual  manner,  the  sabulous 
matters  are  aggregated  by  the  viscid  mucus  and  other  morbid 
secretions  into  masses  moulded  in  one  or  more  of  the  infundibula 
or  the  pelvis ; and  there  they  remain  constituting  urinary  renal 
calculi ; in  which  case  they  may,  either  with  or  without  inflamma- 
tion, cause  obstruction  in  the  excretion  of  the  urine,  and  consequent 
expansion  of  the  renal  infundibula. 

§ 4.  Nephropyema  Calculosa. — Though  it  is  well  ascertained 
that  calculi  if  round  do  not  always  give  rise  to  symptoms  of  un- 
easiness or  pain  in  the  dorso-lumbar  region,  or  to  symptoms  of 
renal  inflammation,  yet  they  are  very  liable  to  do  so  during  the 
operation  of  any  of  the  ordinary  exciting  causes  of  inflammation, 
as  external  violence,  exposure  to  cold,  or  a long  and  fatiguing 
journey  on  horseback,  or  the  operation  of  the  particular  causes  of 
renal  irritation,  as  the  use  of  acidulous  articles  of  food  or  drink, 
the  absorption  or  the  internal  use  of  cantharides,  or  the  use  of  the 
turpentine,  or  resinous,  or  balsamic  articles. 

Either  after  or  without  the  operation  of  one  or  other  of  these 
causes,  the  patient  is  attacked  with  the  symptoms  of  pain  in  the 
dorso-lumbar  region,  shivering,  squeamishness,  numbness  of  the 
thigh,  pain  or  soreness  or  retraction  of  the  testicle  of  the  same  side, 
scanty  urine  or  total  suppression,  or  bloody  sedimentous  urine  and 
constipation.  In  some  cases  the  severity  of  these  symptoms  under- 
goes, either  in  consequence  of  remedies  or  spontaneously,  tempo- 
rary alleviation  ; urine  tinged  brown  with  blood  is  expelled ; and 
shortly  after,  quantities  of  sabulous  matter  or  minute  concretions 
are  discharged. 

In  some  instances  purulent  matter  is  voided  more  or  less  co- 
piously with  the  urine,  and  is  observed  to  fall  to  the  bottom  of  the 
vessel,  presenting  its  usual  appearance  and  characters.  Such  a 
circumstance  is  generally  conceived  to  indicate  suppuration  of  the 
kidney.  In  one  sense  it  certainly  does  denote  the  presence  of  this 
process,  but  not  in  the  sense  commonly  understood.  Though  it 
be  generally  said  that  the  kidney  then  suppurates,  yet  this  is  not 
necessary  either  to  the  termination  of  the  disease,  or  the  appearance 
of  purulent  matter  in  the  iirine.  A more  common  result  is  puru- 


SUPPURATION  OF  THE  KIDNEY. 


937 


lent  or  suppurative  inflammation  of  the  fine  mucous  membrane  of 
the  pelvis  and  infundibula,  and  consequent  distension  of  the  renal 
tubular  cones,  but  without  destruction  of  their  substance.  It  should 
never  be  forgotten,  that  the  presence  of  a urinary  concretion  in  the 
pelvis  or  ureter  may  cause  inflammation  and  suppuration  without 
that  suppuration  affecting  the  proper  substance  of  the  kidney ; and 
that  suppuration  of  the  kidney  may  take  place  without  the  presence 
of  a concretion  in  the  pelvis,  or  ureter,  or  any  of  the  infundibula. 
If  the  stone  be  by  any  means  expelled  and  carried  into  the  bladder, 
the  purulent  matter  may  also  escape,  and  after  being  discharged, 
the  kidney  may  contract,  and  the  morhid  secretion  may  cease. 
Hence  it  is  found  that  discharges  of  purulent  mine  may  take  place 
for  some  time,  and  eventually  cease,  without  preventing  the  patient 
from  recovering  temporarily. 

More  frequently,  however,  the  reverse  is  the  case.  Though  the 
calculus  may  be  discharged,  the  purulent  matter  may  not  be  eva- 
cuated, or  the  purulent  inflammation  continues ; and  even  the  stone 
itself,  forming  a sort  of  cyst  of  the  pelvis  or  ureter,  may  remain 
firmly  impacted,  and  prevent  the  issue  either  of  urine  or  purulent 
matter.  In  either  case,  the  expansion  of  the  kidney  (Nephrotasia) 
continues  and  increases ; the  tubular  cones  are  distended,  com- 
pressed, and  extruded ; the  papillcB  are  compressed,  flattened,  and 
almost  obliterated ; the  cortical  covering  is  also  distended  and  ex- 
tenuated ; and  the  exquisite  stage  of  the  lesion  already  described 
as  Nephropyema  {Pyonephria)  is  fully  established.  Even  ulcera- 
tion of  the  parts  around  the  concretion,  wherever  it  happens  to  be 
fixed,  may  take  place,  and  give  rise  to  great  and  irreparable  ra- 
vages in  the  renal  tissue,  and  that  of  the  contiguous  organs. 

§ 5.  It  is  not  uninteresting  to  trace  the  subsequent  progress  of  this 
disorder,  and  to  observe  what  singular  and  extraordinary  efibrts 
are  sometimes  made  to  counteract  the  mischief  in  the  kidneys,  and 
its  effects  on  the  constitution,  and  to  prevent  the  immediately  fatal 
effects  of  the  disorder. 

Eight  different  terminations  may  in  this  state  of  the  disorder  be 
mentioned. 

a.  The  first  termination  requiring  notice  is,  that  the  disease  may 
pass  into  the  chronic  state,  in  which  the  inflammatory  process  in 
the  infundibula  and  pelvis  continues,  causing  the  secretion  of  puru- 
lent matter,  which  is  voided  with  the  urine,  {pyuria),  and  attended 
with  quick  pulse,  nocturnal  sweatings,  wasting,  and  all  the  symp- 


038 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


toms  of  hectic  fever.  It  is  further  requisite  to  observe,  that  this 
state  is  liable  to  alternate  with,  or  terminate  in,  an  acute  attack  of 
the  disease,  in  which  the  purulent  secretion  is  suddenly  suspended 
or  stopped,  pain  in  the  renal  region  is  induced  or  augmented,  with 
the  other  symptoms  of  renal  inflammation,  and  terminate  not  un- 
usually, if  not  checked,  in  sopor  and  fatal  coma,  with  urinous  ex- 
halation from  the  surface  of  the  body. 

In  those  instances  in  which  a calculus  remains  impacted  in  the 
pelvis  or  ureter,  these  attacks  are  several  times  repeated,  until  the 
kidney  is  very  much  enlarged,  distended,  and  attenuated  by  the 
large  quantity  of  purulent  or  sero-purulent  fluid,  which  never  be- 
ing allowed  to  escape,  is  progressively  augmented  by  the  addition 
of  that  which  is  secreted  at  each  new  attack.  Death  seems  then 
to  be  the  united  result  of  the  repeated  inflammatory  attacks,  and 
the  lesion  inflicted  on  the  structure  of  the  kidney.  Of  this  mode 
of  termination  instances  are  given  by  Tulpius,*  and  Job  a Meek’- 
ren,t  and  a melancholy  and  remarkable  example  occurred,  in  1821, 
in  the  person  of  a medical  practitioner  of  this  city,  in  whose  body 
the  left  kidney  was  found  dilated  so  much,  as  to  contain  nearly 
three  pounds  of  sero-purulent  fluid,  which  had  been  the  product  of 
several  attacks  of  renal  inflammation,  occasioned  by  the  presence 
of  a small  mulberry  calculus,  weighing  only  1^  grain,  impacted  in 
the  upper  end  of  the  ureter.| 

In  such  circumstances,  there  is  reason  to  believe  that  the  dis- 
eased kidney  ceases  to  secrete  urine  ; since  its  texture  is  so  much 
injured,  and  its  circulation  is  employed  in  the  maintenance  of  a 
morbid  secretion ; and  that  the  functions  of  both  are  performed  by 
the  sound  one. 

b.  In  the  second  place,  ulceration  may  take  place  through  the 
pelvis  or  ureter,  and  purulent  matter  escape  into  the  lumbar  and 
pelvic  adipo-cellular  tissue.  Such  a termination  is  necessarily  fatal, 
as  it  induces  a sloughy  mortified  state  of  the  lumbar  and  pelvic 
adipose  membrane,  the  effect  of  which  on  the  system  at  large  is 
speedily  fatal.  Of  this  mode  of  termination  a good  case  is  given 

’ Nicolai  Tulpii  Observationes  Medicse,  8vo.  Amstelod.  1652  and  1672.  Lib.  ii. 
cap.  45. 

+ Jobi  A Meek’ren,  Chirurgi  Amstelodamensis  Observationes  Medico-Chirurgicaj 
Amstelodami  1682,  cap.  xlv.  The  Memoirs  of  the  Royal  Society  of  Medicine  (1780-8 1 
Paris,  p.  272)  ; Fourcroy,  Medecine  Eclairee  par  les  Sciences  Physique,  ii.  p.  253. 

X Edinburgh  Medical  and  Surgical  Journal,  vol.  xviii.  p.  557  and  561. 


TERMINATIONS  OF  SUPPURATION  OF  THE  KIDNEY.  939 


by  Mr  Howship,  in  case  7,  (p.  43),  in  a person  between  60  and 
70  years  of  age,  in  whom  the  matter  eventually  passed  by  a small 
round  ulcerated  aperture  of  the  peritonasum  into  the  general  ab- 
dominal cavity.  A similar  case  is  recorded  by  Chomel.* 

c.  In  the  third  place,  the  matter  may  pass  directly  through  the 
■peritonaum  into  the  cavity  of  the  abdomen,  establishing  a direct 
communication  between  the  infundibula  and  pelvis  of  the  kidney 
and  the  latter  cavity.  This  is  mentioned  by  Chopart ; but  it  seems 
to  be  questioned  by  Chomel,  because  no  cases  are  specified  by  the 
former.  It  is  proper  to  mention,  therefore,  that  an  instance  of  this 
mode  of  suppurative  destruction  is  afforded  in  the  sixth  case  by  Mr 
Howship,  (p.  49,)  taking  place  in  the  person  of  a boy  of  7,  who 
had  laboured  under  symptoms  of  urinary  disorder  from  the  age  of 
18  months,  and  in  whom  both  kidneys,  but  especially  the  left,  pre- 
sented marks  of  suppurative  inflammation,  and  a communication 
had  been  established  between  the  surface  of  the  left  kidney  and  the 
cavity  of  the  peritonaeum,  and  the  matter  had  thereby  escaped  into 
the  interior  of  the  latter. 

d.  A fourth  mode  in  which  the  purulent  matter  may  escape,  is 
into  the  transverse  arch  of  the  colon,  especially  if  it  be  the  left 
kidney.  Of  this  mode  of  issue  Fantoni  records  an  instance ; and 
in  the  year  1832,  in  inspecting  the  body  of  a woman  destroyed  by 
cholera,  I found  a state  of  parts  which  shows  that  the  same  issue 
must  have  taken  place  in  that  case.  In  the  transverse  arch  of  the 
colon  was  a fistulous  opening  leading  into  the  pelvis  of  the  right 
kidney,  in  which  and  the  expanded  renal  substance  was  contained 
a large  calculus. 

e.  In  the  fifth  place,  the  communication  may  open,  and  the  mat- 
ter be  evacuated  into  the  sigmoid  flexure  or  rectum.  Of  this  an 
instance  is  recorded  by  Bonnetf  in  the  person  of  a young  woman. 

f.  A sixth  mode  in  which  renal  abscess  has  been  observed  to  pro- 
cure an  outlet  for  itself  is  by  producing  ulcerative  destruction  of 
the  diaphragm  and  pleura^  and  evacuating  its  contents  into  the 
lungs  and  bronchi.  Of  this  De  Haen  gives  an  instance,  in  which, 
in  the  person  of  a young  man  of  15,  after  symptoms  of  renal  in- 
flammation, purulent  matter  was  first  voided  with  the  urine,  and, 

* Archives  Gen.  xliii.  p.  12. 

t Journal  Hebclomadaire,  Tome  vii,  p.  397.  Archives  Generales,  Tome  xxiv.  p. 
278. 


940 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


after  the  interval  of  three  or  four  years,  during  which  the  indivi- 
dual recovered  his  health  so  far  as  to  be  able  to  marry,  he  was  at- 
tacked with  symptoms  of  intense  inflammation  of  the  chest,  he  ex- 
pectorated fetid  sanious  reddish  purulent  mattei’,  and  had  most  la- 
borious breathing ; and  eventually  he  died  hectic.  It  was  then 
found  that  the  left  kidney  was  dilated  into  a large  sac  or  cyst  with- 
out any  trace  of  the  original  gland ; the  ureter  was  distended  to 
the  size  of  the  small  intestine,  and  was  filled  with  purulent  matter ; 
a large  aperture  was  found  in  the  diaphragm,  forming  a direct 
communication  between  the  left  kidney  and  the  lower  lobe  of  the 
left  lung,  which  was  destroyed,  with  the  lower  part  of  the  upper 
lobe.* 

g.  A seventh  mode  in  which  the  renal  abscess  may  procure  an 
issue  for  its  contents  is  into  and  through  the  liver  or  spleen,  the 
right  kidney  by  the  former,  the  left  by  the  latter,  towards  the  sur- 
face. This  mode  of  termination,  which  is  assigned  by  Peter  Frank, 
is  received  with  doubt  by  Chomel.  It  may  be  observed,  however, 
that  Mr  Howship  gives  in  his  eighth  case,  (p.  47),  the  history  of  an 
attack  of  inflammation  of  the  right  kidney,  in  which  a large  abscess 
of  the  right  kidney  pointed  over  the  region  of  the  liver,  and  was 
there  opened,  and  discharged  five  pints  and  a half  of  matter ; and 
though  after  death,  w'hich  took  place  forty-two  days  after  the  ope- 
ration, the  substance  of  the  liver  was  found  healthy,  its  inferior  sur- 
face was  united  by  adhesion  to  the  superior  extremity  of  the  right 
kidney. 

li.  In  the  eighth  place,  the  matter  of  the  renal  abscess  may  open 
a path  for  itself  posteriorly  through  the  back  part  of  the  pelvis  or 
ureter  or  kidney,  and  the  dorso-lumbar  cellular  tissue,  muscles, 
and  fasciae,  so  as  to  point  on  one  or  other  side  of  the  spine.  Of 
all  the  modes  of  proceeding  outward,  this  is  the  one  which  has  been 
most  frequently  observed ; and  as  it  has  often  suggested  to  surgeons 
the  expediency  of  making  an  incision  in  suspected  cases  of  renal 
concretion,  it  is  chiefly  in  the  writings  of  surgeons  that  accounts  of 
it  are  given. 

Of  this  mode  of  issue,  instances  are  recorded  by  Fantoni,  Tulpius,f 
Job  a Meek’ren,J  Cheselden,§  Petit.|| 

The  concretion  giving  rise  to  ulceration,  first  of  the  kidney  or  its 

* Ratio  Medendi,  Tom.  x.  p.  103. 

f IV.  chap.  27.  J Cap.  xliv.  § Anatomy,  Book  iv.  chap.  1. 

II  Oeuvres  Po.sthumes,  iii.  p.  73,  and  in  the  Memoirs  of  the  Academy  of  Chirurgery, 
ii.  p.  233. 


GANGRENE  OF  THE  KIDNEY. 


941 


pelvis,  or  the  top  of  the  ureter,  causes  at  the  same  time  suppurative 
and  adhesive  inflammation,  proceeding  gradually  to  the  surface, 
where  it  forms  a prominent  tumour,  red,  painful,  soft,  and  fluctu- 
ating, and,  either  a spontaneous  opening  taking  place  or  after  an 
incision,  matter  is  discharged,  and  not  unusually  with  that  one  or 
more  urinary  calculi,  or  sabulous  matter  and  urine.  The  swelling 
subsides  after  the  first  discharge  of  matter  ; but  the  aperture  evinces 
no  disposition  to  close,  and  matter  continues  to  be  discharged  for 
months  or  years,  while  a long  sinus  or  fistula  leading  to  the  kidney 
is  maintained.  It  is  then  a renal  fistula,  discharging  matter,  and 
sometimes  urine  and  sand,  or  urinary  concretions.  If  the  opening 
happen  to  become  closed,  much  pain  is  produced,  and  all  the  for- 
mer symptoms  of  nephritis  ensue,  until  fresh  suppuration  takes  place, 
and  the  aperture  is  reopened.  Hence  Lassus,* * * §  Monteggia,f  Boyer,| 
and  other  surgeons,  recommend  that  the  fistula  he  kept  open  by  a 
bougie,  a cannula,  prepared  sponge,  or  a bit  of  charpie,  in  short,  by 
some  dilating  body. 

As  in  most  of  the  cases  now  specified,  the  local  disorder  of  the 
kidney,  if  it  do  not  prove  immediately  fatal,  gives  rise  to  more  or 
less  hectic  fever,  with  wasting  and  loss  of  strength.  The  condition 
of  the  system  thus  induced  was,  early  designated  by  the  name  of 
renal  consumption,  {^phthisis  renalis)^.  This  name,  though  retain- 
ed by  Hildenbrand  and  several  moderns,  is  not  proper,  because  it 
is  liable  to  lead  to  confusion  ; since  the  term  phthisis  is  no  longer 
general,  but  has  been  by  most  modern  nosologists  restricted  to  the 
particular  form  of  wasting  which  depends  on  tubercular  destruc- 
tion of  the  lungs.  A more  convenient  appellation  would  be  tabes 
renalis, 

§ 6.  Gangrene. — The  question  whether  renal  inflammation  ever 
terminates  in  gangrene  has  been  proposed  by  Chomel.  Fabricius 
Hildanus  mentions  that  in  his  own  son,  a boy  of  9,  he  found  the 
kidneys  and  neighbouring  parts  inflamed  and  degenerated  into 
gangrene ; and  Chopart  records  the  case  of  a person  of  62,  who 
died  on  the  ninth  day  of  symptoms  of  nephritis,  in  whose  body  he 
found  the  kidneys  bulky,  livid,  mottled  with  blackish  spots,  and 
easily  lacerable.  In  neither  of  these  cases  does  the  pathologist  re~ 

* Pathologie  Chirurgicale,  i.  xxvii.  p.  163. 

t Istituzione  Chirurgiche. 

+ Traite  des  Maladies  Chirurgicales,  T.  viii.  p.  SOS,  SOS. 

§ Jac.  Fabricii,  Disputatio  de  Phthisi  RenaU.  Giessse,  1699. 


942 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


cognize  positive  evidence  of  gangrene ; and  Chomel  is  therefore 
inclined  to  doubt  the  termination ; but  he  allows  that,  in  cases  of 
persons  who  have  died  after  long  continued  suppuration  of  the 
kidney,  some  parts  of  the  suppurating  surface  presenting  the  dark 
colour,  or  grayish,  the  peculiar  odour,  the  softness,  and  the  absence 
of  apparent  organization  observed  in  mortified  sloughs. 

As  an  instance  of  this  lesion,  Walter  records  a curious  case 
which  took  place  in  the  person  of  a young  woman  who  had  labour- 
ed for  many  years  under  violent  pains  in  the  region  of  the  kidneys ; 
and  who  was  at  length  attacked  with  inability  to  void  urine,  in 
place  of  which  she  had  a continual  discharge  of  purulent  matter, 
mixed  with  blood  and  fine  sand.  The  belly  swelled  so  much  that 
she  was  imagined  to  be  pregnant ; but  she  suddenly  fell  down  dead. 
Upon  inspecting  the  body,  Walter  found  the  right  kidney  enlarged 
into  a great  spheroidal  swelling,  ten  inches  in  the  long  diameter, 
six  in  the  transverse,  its  substance  of  a brownish-red  colour,  very 
soft,  and  so  easily  lacerable,  that  on  the  slightest  touch  an  opening 
was  made.  Internally  it  was  altogether  consumed,  and  its  cavity 
was  filled  with  an  astonishing  quantity  of  coagulated  blood,  puru- 
lent matter,  and  dissolved  renal  substance.  This  mixture,  which 
resembled  a sort  of  soup,  enclosed  two  concretions,  one  weighing 
two  drachms,  the  other  two  scruples,  which  could  not  be  discovered 
till  some  of  the  mixture  was  emptied.  On  further  investigation, 
Walter  found  that  some  of  the  large  renal  vessels  had  been  eroded 
and  laid  open,  and  to  this  he  ascribed  the  sudden  death  of  the  wo- 
man, and  the  quantity  of  blood  found  in  the  kidney.* 

This,  I think,  must  be  regarded  as  a pretty  unequivocal  case  of 
gangrene  of  the  kidney.  The  termination  must,  nevertheless,  he 
regarded  as  rare. 

Vogel  gives,  in  a man  affected  with  jaundice,  an  example  of  the 
kidney  labouring  under  gangrene.  The  chief  characters  are  masses 
of  clotted  and  decomposed  blood  disseminated  through  the  paren- 
chyma of  the  gland.f 

Mortification  of  the  perinephral  adipose  membrane  is  a common 
consequence  of  infiammation  of  that  tissue.  But  it  belongs  to 
another  head. 

§ 7.  a.  Suppurative  inflammation  of  the  Kidney. — Though 

* Einige  Krankheiten  dcr  Nieren  und  Harnblase.  4to.  Berlin,  1800.  § 11, 

seite  0. 

•f  Tabula  xxiii. 


SUPPURATION  OF  THE  KIDNEY. — CHONDROSIS. 


943 


1 have  represented  suppuration  of  the  kidney  to  commence,  in  or- 
dinary circumstances,  in  the  interior  of  the  calyces  and  pelvis,  and 
rather  to  produce  a sort  of  expansion  and  distension  of  the  gland 
than  an  actual  purulent  destruction,  it  is,  nevertheless,  necessary 
to  say,  that  purulent  destruction  does  take  place  in  the  substance  of 
the  kidney.  Of  this  I have  seen  several  instances.  In  these  cases, 
the  whole  kidney  was  completely  converted  into  a quantity  of  thick 
purulent  matter,  partly  like  thin  putty,  partly  more  fluid,  all  of 
which  was  contained  within  the  renal  capsule,  like  atheromatous 
matter  in  a hag  or  cyst. 

In  all  the  cases  of  this  disorder,  excepting  one,  the  patients  pre- 
sented no  evident  or  prominent  symptoms  which  could  lead  to  the 
suspicion  that  the  kidney  was  in  a state  of  inflammatory  disease. 
In  one  case,  death  took  place  after  an  obscure  illness  of  a few  days. 
In  the  case  which  I have  mentioned  as  an  exception,  the  patient 
was  hectic,  and  had  uneasiness  in  the  bladder  and  along  the  ureters ; 
but,  as  it  was  plai«  that  the  lungs  were  tuberculated  and  presented 
open  vomicae,  the  hectic  symptoms  were  justly  ascribed  to  the  pre- 
sence of  the  pulmonary  disorganization.  If  we  say  that  this  lesion 
is  of  strumous  origin,  we  merely  give  another  answer,  without  com- 
ing more  closely  to  the  explanation.  It  seems  as  if  the  whole  re- 
nal tissue,  cortical  and  tubular,  were  liquefied  or  dissolved  in  pu- 
rulent matter. 

b.  Small  patches  of  purulent  matter  are  occasionally  observed 
in  the  cortical  or  in  the  tubular  part  of  the  kidney,  without  appa- 
rent connection  with  inflammation  of  the  calyces.  These,  I think, 
must  be  admitted  to  be  of  strumous  origin.  In  one  instance,  in 
which  I witnessed  this  state  of  the  kidneys,  it  took  place  in  the  body 
of  a sickly  strumous  boy  of  fifteen  years,  who  died  of  lobular 
'pneumonia ; and  it  is  usually  seen  in  young  subjects. 

c.  In  some  instances  of  inflamed  vein,  purulent  matter  has  been 
found  in  the  substance  of  the  kidney.  This  has  been  regarded  as 
metastatic ; but  it  is  most  correct  to  look  on  it  as  transported  from 
the  vein  inflamed  to  this  in  common  with  other  internal  organs. 

§ 8.  Cartilaginous  induration  of  the  Ureters  and  Pelvis,  'produc- 
ing or  accompanied  with  Renal  Inflammation. — It  is  proper  to  men- 
tion here,  that  the  ureters  and  pelvis  are  liable  to  a particular  kind 
of  chronic  inflammation,  inducing  great  thickening  and  induration 
of  the  mucous  membrane,  with  roughness  of  its  inner  surface.  In 
the  most  marked  case  of  the  disorder  which  I have  seen,  this  state 


944 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


extended  from  the  bladder  upwards,  through  the  ureters  on  both 
sides  into  the  pelvis  and  calyces  of  the  kidneys.  The  ureters  were 
rendered  thick  and  firm  like  cartilage ; their  size  was  increased  to 
about  five  or  six  times  the  usual  dimensions ; their  canal  was  also  en- 
larged ; and  their  firmness  prevented  them  from  collapsing,  as  in  the 
healthy  state.  The  morbid  state  now  mentioned  appeared  to  have 
originated  in  the  mucous  membrane,  but  eventually  to  have  affected 
the  other  tissues.  It  was  difficult  to  say  whether  it  had  commenced 
in  the  membrane  of  the  calyces  or  in  that  of  the  ureter,  and  extended 
to  the  former ; for  both  were  affected  in  nearly  equal  degrees. 

This  change  was  accompanied  with  painful  and  difficult  micturi- 
tion, the  urine  containing  puriform  mucus  and  sand ; with  quick  pulse, 
much  thirst,  hot  dry  skin,  alternating  with  shiverings  and  sweat- 
ings, wasting,  loss  of  strength,  a most  anxious  miserable  expression 
of  the  countenance,  and  slight  incurvation  of  the  person,  as  if  un- 
der the  suffering  of  much  pain.  The  disease  had  been  of  long 
duration,  at  least  several  months. 

§ 9.  Disease  of  the  Kidneys  simulating  disease  of  the  Spinal 
Chord;  and  inflammation  of  the  Calycine  Membrane  from  injury  or 
disease  of  the  Spinal  Chord. — A singular  effect  of  renal  inflamma- 
tion and  suppuration  is  to  induce  paraplegia  and  symptoms  of  dis- 
eased spine.  It  has  been  long  known  that  injuries  and  diseases 
chiefly  of  an  inflammatory  character  in  the  spine  or  spinal  cord,  are 
liable  to  be  followed  by  various  morbid  states  of  the  urinary  secre- 
tion, which  is  generally  rendered  alkalescent  or  ammoniacal,  some- 
times deposits  the  ammoniaco-magnesian  phosphate,  sometimes  the 
carbonate  of  ammonia.  Bellingeri  had  observed,  that  in  animals, 
after  experiments  on  the  spinal  chord,  inflammation  was  liable  to 
attack  the  kidneys  and  the  peritoneum,  and  render  the  former  red 
and  vascular,  and  cover  them  with  lymph.  Mr  Stanley  has  shown, 
by  a judicious  selection  of  cases,  that  when  the  spinal  chord  is  sup- 
posed to  be  diseased  or  injured,  either  directly  or  in  consequence  of 
disease  or  injury  of  the  vertebrae,  causing  pain  in  the  back  and 
paraplegia,  the  symptoms  so  produced  do  not  originate  from  dis- 
ease of  either  the  vertebra,  the  chord,  or  the  membranes,  all  of 
which  are  sound,  but  from  inflammation  or  suppuration  of  the 
kidneys,  in  which  in  general  are  found  collections  of  purulent 
matter.  From  such  cases  it  must  be  inferred,  as  Mr  Stanley  has 
done,  that  disease  originating  in  the  kidneys  simulates,  and  may 
give  rise  to  disease  in  the  spinal  chord,  probably  by  a reflected  in- 

4 


INFLUENCE  OF  DISEASE  OF  SPINAL  CHORD, 


945 


fluence  from  the  diseased  gland  through  its  nerves  to  those  con- 
nected with  the  spinal  chord.  It  may  conversely  be  inferred,  that 
in  any  morbid  state  of  the  spinal  chord,  the  impaired  influence  of 
the  nerves  over  the  renal  action  allowing  the  urine  to  be  secreted 
in  the  kidney  in  an  alkaline  state,  gives  rise  to  a new  train  of  evils, 
by  the  irritation  necessarily  induced  in  the  tubular  part  of  the  kid- 
ney and  in  the  calycine  membrane.  The  ammoniacal  urine  then 
irritates  perhaps  both  the  cortical  and  the  tubular  part  of  the  glands, 
and  must  certainly  irritate  the  calycine  membrane,  and  is  the  cause 
of  the  inflammatory  states  which  it  often  presents.  On  this  head  I 
refer  the  reader  to  the  paper  of  Mr  Stanley,*  and  to  what  I have 
in  another  place  said  under  the  section  on  Myelitis.^ 

The  PROGNOSIS  in  Nephritis  is  in  general  not  favourable.  But 
it  is  more  favourable  when  the  disorder  is  the  result  of  external 
violence,  than  when  it  is  the  efiect  of  any  internal  cause.  In  gouty 
and  calculous  patients,  the  prognosis  is  unfavourable,  because  it 
generally  after  one  attack  recurs  several  times,  until  it  undermines 
the  strength  by  renal  or  vesical  calculus,  or  by  the  formation  of 
renal  abscess,  or  by  total  suppression  (^Ischuria  renalis\  causes 
speedy  death. 

Renal  abscess  or  fistula,  though  almost  uniformly  leading  to 
death,  is  not  necessarily  a fatal  disorder ; but  in  whatever  of  the 
forms  specified  it  appears,  life  is  always  maintained  in  a most  un- 
comfortable and  precarious  condition.  The  least  unfavourable  is, 
where  none  of  the  unnatural  communications  or  fistulce  have  taken 
place,  and  where  the  purulent  matter  has  procured  an  outlet  for 
itself  through  the  ureter  into  the  bladder,  and  thence  been  dis- 
charged externally.  In  some  instances,  recovery  has  been  effected 
after  this  event  had  taken  place.  Forest  mentions  (lib.  xxiv,  obs. 
37),  the  case  of  a priest,  who,  after  discharging  purulent  urine  for 
three  months,  and  being  reduced  to  the  greatest  emaciation,  reco- 
vered under  the  use  of  proper  regimen,  consisting,  chiefly  of  milk. 
M.  Chomel  records  a case  from  M.  Meniere  of  the  Hotel  Dieu,  in 
which  a similar  recovery  must  have  taken  place.  The  right  kidney 
was  shrunk  into  an  irregular  mass,  about  the  size  of  a pigeon’s  egg, 
forming  a species  of  membranous  sac,  consisting  of  the  calyces, 
pelvis,  and  ureter,  containing  about  half  an  ounce  of  clear  fluid, 

* On  Irritation  of  the  Spinal  Chord  and  its  Nerves  in  connection  rvith  Disease  in  the 
Kidneys.  By  Edward  Stanley,  F.  R.  S.,  &c.  Medico-Chirurgical  Transactions,  xviii. 
p.  260.  London,  1833. 

t Elements  of  Practice  of  Medicine,  Vol.  ii.  p.  398. 

3 o 


946 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


but  totally  void  of  any  trace  of  cortical  or  tubular  portions.  This 
constitutes  what  some  have  named  Atrophy  of  the  kidney,  which, 
doubtless,  is  the  effect  of  suppurative  destruction,  followed  by  con- 
traction of  the  remaining  parts. 

Renal  inflammation  must  be  distinguished  from  the  symptoms 
produced  by  a calculus  in  the  ureter,  from  lumbago,  from  psoitis 
and  lumbar  abscess,  from  peritonitis,  intestinal  inflammation,  colic, 
granular  disease  of  the  kidneys,  and  from  spinal  irritation  and  in- 
flammation, and  disease  of  the  spine  generally. 

§ 10.  Granular  Disease — Steatosis — Stearosis  of  Gluge. 
This  consists  in  a change  in  the  structure  of  the  kidney,  especially 
its  cortical  or  secreting  portion,  in  which  it  is  penetrated  with  gray- 
ish, whitish,  yellowish,  or  fawn-coloured  adipose  matter,  in  the  form 
of  minute  granules ; and  in  which,  at  the  same  time,  the  density  of 
the  urine  is  diminished,  and  the  urine  contains  less  urea  than  it 
ought,  and  more  or  less  albumen  or  serum,  the  presence  of  which 
may  be  shown  by  the  application  of  heat,  or  the  addition  of  any  of 
the  acids  or  the  metallic  salts. 

The  texture  of  the  kidney,  especially  its  cortical  portion,  is  liable 
to  become  changed  in  various  modes,  and  it  presents  in  the  different 
stages  of  each  diflferent  appearances. 

It  is  rare  to  observe  kidneys  in  the  first  stage  of  this  disease  in 
any  of  its  forms,  as  it  is  not  at  that  period  by  itself  fatal ; and  it 
may  be  doubted  whether  it  has  been  seen  in  the  incipient  stage. 
The  following  varieties,  however,  may  be  regarded  as  the  most 
usual. 

1.  The  kidney  may  be  of  a very  dark-red,  or  brown  colour,  much 
loaded  with  blood,  and  its  vessels  very  much  enlarged.  The  tubu- 
lar is  always  of  a darker  colour  than  the  cortical  part ; but  the 
latter  is  in  this  case  extremely  dark-coloured.  When  it  is  divided 
by  a longitudinal  incision,  the  surface  of  the  section  is  altogether 
much  darker  than  natural,  being  a deep  chocolate  brown,  while 
the  cortical  portion  appears,  though  darker  than  natural,  yet  lighter 
coloured  than  the  tubular,  and  presents  the  aspect  of  a brownish 
red  mass,  surrounding  and  enclosing  dark-brown,  or  amber-brown 
coloured  tubular  cones.  The  outer  surface  of  the  gland,  stripped 
of  its  tunic,  is  also  very  dark-coloured,  reddish  brown,  inclining  to 
chocolate  red,  is  less  smooth  than  natural,  and  may  even  be  a little 
rough  and  irregular,  presenting  small  depressions  containing  blood- 
vessels in  clusters,  and  the  gland  is  in  general,  in  this  variety  and 


STEATOSIS  OR  GRANULAR  DISEASE  OF  THE  KIDNEY-  947 


stage  of  the  disorder,  soft  and  flaccid.  The  whole  gland  is  large, 
flabby,  and  very  vascular. 

This  form  of  the  disorder  is  seen  chiefly  in  persons  who  have 
died  from  fever  or  pneumonia,  or  pleurisy,  or  in  children  with 
symptoms  of  afiection  of  the  brain. 

2.  In  one  variety  next  to  be  mentioned,  the  kidneys  are  large, 
soft,  and  flaccid ; and  when  the  tunic  is  stripped,  the  exterior  sur- 
face, though  less  deep  in  colour,  is  still  more  irregular  than  in  the 
last  mentioned  variety.  The  colour,  indeed,  begins  to  assume  a 
gray  or  fawn  tint,  the  brown  being  less  deep,  and  giving  place  to 
chestnut-brown  or  yellowish-brown.  The  irregular  appearance  on 
the  surface  is  produced  by  numerous  depressions  with  alternate 
elevations.  In  the  last  case,  the  depressions  are  so  few  in  number 
that  they  leave  between  them  considerable  smooth  spaces  of  the 
outer  surface  of  the  kidney.  But  in  this  variety  the  spaces  between 
the  depressions  are  so  small,  and  the  depressions  are  so  numerous, 
that  the  whole  outer  surface  appears  to  consist  of  manifold  alternate 
pits  and  elevations.  These  pits  are  remarkable  for  containing  little 
clusters  of  red  vessels.  Sometimes,  if  the  surface  be  attentively 
inspected  by  the  eye,  and  always  by  the  aid  of  the  microscope, 
minute  gray-coloured  bodies  like  grains  may  be  recognized  depo- 
sited in  the  cortical  substance,  decidedly  differing  from  the  latter 
in  the  lighter  colour  which  they  present.  Upon  dividing  such  a 
kidney  as  this  by  a longitudinal  section,  the  change  in  structure  is 
still  more  conspicuous.  The  cortical  portion  has  throughout  be- 
come of  a lighter  colour  than  natural,  and  is  generally  some  shade 
of  orange,  fawn,  or  yellow.  Thus  it  may  be  buff-orange,  which  is 
a light  stone  colour,  or  reddish  orange, — a salmon  red  tint,  or 
deep  reddish  orange,  or  it  may  vary  between  these  and  honey-yel- 
low, sienna-yellow,  or  ochre-yellow.  When  inspected  carefully, 
even  by  a good  practised  eye,  and  much  more  by  the  aid  of  a glass 
of  moderate  magnifying  powers,  this  change  in  colour  may  be  traced 
to  innumerable  little  granular  bodies,  infiltrated,  as  it  were,  or  de- 
posited in  the  cortical  substance,  varying  in  size  from  the  point  to 
the  head  of  a pin.  These  bodies  consist  of  the  epithelial  cells  of 
the  tubuli  infiltrated  with  fat,  and  the  tuhuli  themselves  infiltrated 
with  albuminous  deposit.  The  cortical  or  secreting  matter  of  the 
kidney  has  then  in  general  lost  most  of  its  peculiar  striated  arrange- 
ment ; and  presents  the  appearance  of  reddish  orange,  or  honey 
yellow,  or  fawn-coloured  matter,  enclosing  the  tubular  cones,  and 


948 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


appearing  as  it  were  to  encroach  on  their  bounds  and  pass  between 
them.  The  tubular  cones,  though  retaining  their  colour,  seem 
then  rather  smaller  than  usual,  and  appear  like  reddish  oval-shaped 
bodies,  enclosed,  as  it  were,  in  the  gray  or  orange-coloured  corti- 
cal matter. 

The  extent  to  which  this  transformation  proceeds  varies  in  diffe- 
rent kidneys  and  in  different  portions  of  the  same  kidney.  In  some 
cases  it  commences  in  one  of  the  extremities  of  the  gland,  and  either 
extremity  is  then  seen  to  be  more  remarkably  changed  than  other 
parts.  In  other  instances,  it  commences  in  the  centre  of  the  gland 
or  rather  the  centr-al  part  of  the  cortical  matter ; and  then  this  part 
is  most  completely  transformed. 

In  consequence  of  the  peculiar  change  in  the  colour  of  the  sur- 
face, the  pits  in  which  are  of  a darker  colour  than  the  elevations  and 
intermediate  portions,  the  kidney  now  described  is  said  to  be  mottled. 

3.  Without  increase  in  size  or  change  in  consistence,  the  cor- 
tical part  of  the  kidney  may  be  penetrated  or  infiltrated  with  gra- 
nular albuminous  matter  in  various  modes  and  degrees. 

a.  In  one  variety  which  appears  to  be  comparatively  in  an  early, 
though  not  an  incipient  stage,  when  the  gland  is  stripped  of  its  tu- 
nic, the  surface  is  irregular,  rough,  or  as  it  were  sprinkled  with 
fine  sand,  of  a reddish  gray  colour,  with  more  of  the  former  than 
the  latter ; and  part  of  the  cortical  matter  not  unusually  comes  off 
adhering  to  the  tunic.  The  surface  presents  also  small  hollows  or 
pits,  containing  blood-vessels  as  in  the  last  variety ; and,  indeed, 
this  appearance  is  one  of  the  most  constant.  When  the  surface  is 
closely  inspected,  numerous  minute  reddish  gray  granules  may  be 
recognized,  not  aggregated  together,  but  separately  infiltrated  into 
the  cortical  matter.  When  the  gland  is  divided  by  a longitudinal 
section,  part  of  the  striated  texture  of  the  cortical  part  is  still  re- 
cognized in  the  form  of  reddish-coloured  streaks,  extending  from 
the  circumference  to  the  tubular  cones ; but  all  the  rest  of  the  cor- 
tical part  of  the  kidney  is  of  reddish  gray  colour,  lighter  than  usual, 
and  when  minutely  inspected  either  by  the  eye  or  with  the  aid  of  a 
lens,  small  cream-coloured  or  grayish  coloured  granular  bodies  are 
observed  dispersed  through  the  cortical  matter. 

In  such  a kidney  as  this,  if  coloured  glue  or  isinglass  be  thrown 
into  the  blood-vessels,  it  does  not  perfectly,  as  in  the  healthy  state, 
fill  the  cortical  matter  of  the  gland.  The  healthy  parts  only,  or 
those  which  still  retain  the  striated  texture,  are  reddened  by  the  in- 


STEATOSIS  OR  GRANULAR  DISEASE  OF  THE  KIDNEY.  949 


jected  size ; while  the  diseased  and  gray-coloured  portions  receive 
little  or  none  of  the  injected  size. 

In  general,  kidneys  in  this  state  are  of  the  natural  size,  and,  in- 
stead of  being  soft  and  flaccid,  are  either  of  normal  consistence,  or 
a little  firmer  than  natural. 

b.  In  a variety,  which  is  perhaps  in  a more  advanced  stage  of 
progress,  the  outer  surface  of  the  gland,  if  stripped  of  its  capsule,  is 
still  more  extensively  marked  with  pits  containing  clusters  of  blood- 
vessels, so  that  the  whole  surface  is  irregular  and  vascular.  These 
blood-vessels  are  star-like  or  asteroid,  branch-like  or  ramiform,  or 
in  the  shape  of  small  dots  and  points,  stigmatoid  ; and,  according 
to  the  number,  the  size,  and  the  aggregation  of  these  clusters,  the 
external  surface  of  the  gland  is  red  and  vascular  or  otherwise.  Be- 
sides this  vascular  redness  in  pits  and  hollows  of  the  surface,  the 
whole  gland  is  moulded  as  it  were  into  irregular  large  hollows  and 
elevations,  so  as  to  seem  tuberculated  or  mammillated.  Of  the 
parts  not  vascular  the  colour  is  a sort  of  stone-gray  or  light  reddish 
yellow,  or  fawn-coloured,  in  considerable  masses,  so  as  to  render 
the  surface  mottled  or  rather  marbled. 

A longitudinal  section  of  a kidney  in  this  state  often  shows  a 
very  complete  change  in  the  cortical  texture.  It  presents  little  or 
no  remains  of  striated  matter  ; but  the  whole  cortical  portion  is  one 
uniform  mass  of  yellowish  gray,  or  buff-orange,  or  sienna  yellow, 
or  cream-yellow.  In  this  case  the  new  matter  is  not  merely  infil- 
trated, but  it  is  so  diflFused  that  the  cortical  portion  is  transformed 
into  it.  A few  tubular  cones  still  remain  more  or  less  complete ; 
but  either  they  become  transformed  into  the  gray-coloured  deposit, 
or  the  transformed  cortical  matter  has  so  much  encroached  on  them 
as  to  have  diminished  much  their  usual  dimensions. 

The  shape  of  the  kidney  in  this  variety  sometimes  presents  a 
singular  deviation  from  the  natural  standard.  The  gland  is  ta- 
pered at  each  end,  so  as  to  present  an  apex  more  or  less  acumina- 
ted, instead  of  the  usual  rounded  end  of  the  gland.  I am  unable 
to  say,  whether  this  change  in  figure  is  congenital  or  the  effect  of 
the  disease. 

The  cortical  matter  of  the  kidneys,  so  far  transformed  as  in  this 
variety,  is  almost  altogether  incapable  of  receiving  injection. 

4.  In  the  next  varieties,  it  may  seem  doubtful  whether  they  are 
different  from  the  last,  or  only  the  most  advanced  stages  of  the 
transformation  and  deposition. 

The  external  surface  of  the  kidney  is  of  a slate-gray  or  leaden- 


950 


GENERAL  AND  rATIlOLOGICAL  ANATOMY. 


gray  colour,  and  presents,  or  may  be  said  to  consist  of,  numerous 
globular  granules  aggregated  together.  These  globules  vary  in 
size  from  a small  pin  head  to  a millet  seed,  or  the  grains  of  sago, 
and  are  mostly  of  the  sienna- yellow,  or  cream-yellow,  or  stone-gray 
colour,  but  in  some  parts  they  are  of  leaden-gray.  Various  patches 
also  of  the  kidney  present  this  leaden- gray  tint,  which  may  be  traced 
partly  to  the  intermediate  spaces  or  lines,  partly  to  the  globular 
granules  themselves.  None  of  the  striated^  texture  of  the  cortical 
matter  can  be  recognized  in  this  variety,  in  which  the  cortical  mat- 
ter appears  to  be  completely  converted  or  transformed  into  the  new 
formation.  In  the  longitudinal  section  of  this  all  that  is  seen  is  the 
appearance  of  a uniform  mass  of  sienna-yellow  animal  matter,  with- 
out trace  of  distinct  organization,  sometimes  minute  granular  bodies, 
but  almost  never  any  striated  texture. 

The  tubular  cones  retain  a colour  more  or  less  bright  red,  and, 
being  enclosed  in  this  buff-coloured  morbid  texture,  present  a strik- 
ing contrast  to  the  state  of  the  healthy  kidney.  Sometimes  they  are 
diminished  in  size,  and  sometimes  in  the  section  made  one  or  two 
of  them  seems  either  to  have  disappeared,  while  in  the  place  which 
they  should  have  occupied,  buff-coloured  matter  is  deposited,  or  to 
have  been  converted  into  a firm,  solid,  gray-coloured  matter.  This 
variety  of  change  is  also  unsusceptible  of  injection. 

The  kidneys  in  this  state  are  almost  invariably  firm  and  hard,  and 
are  sometimes  smaller  than  usual. 

5.  It  is  very  diflicult,  if  not  impracticable,  to  distinguish  all  the 
various  forms  of  this  buff-coloured  or  sienna-yellow  transformation 
of  the  cortical  matter  of  the  kidney.  Most  of  them  difler  chiefly  in 
the  shades  of  colour  which  the  transformed  cortical  matter  assumes, 
and  the  degree  in  which  the  striated  matter  has  disappeared,  and 
in  which,  consequently,  the  kidney  has  become  incapable  of  receiv- 
ing injection.  The  most  usual  colour  in  this  stage,  which  is  per- 
haps the  concluding,  is  some  shade  of  sienna-yellow,  sometimes 
inclining  to  buff-orange,  or  to  tile-red.  In  some  rare  cases  the 
colour  of  the  new  deposit  is  lemon-yellow  or  gamboge-yellow.  In 
others,  it  is  of  a tawny  colour.  In  all  these  cases  the  kidney  is  in 
general  small  and  firm,  sometimes  almost  cartilaginous. 

The  kidney  is  liable  to  the  same  kind  of  change  in  the  dropsy 
which  follows  scarlet  fevej\  In  some  instances,  the  cortical  portion 
is  merely  mottled  or  marbled,  and  its  surface  presents  superficial 
hollows  containing  clusters  of  blood-vessels,  while  the  section  of  the 
gland  shows  part  of  it  changed  in  colour,  though  with  remains  of 


STEATOSIS  OR  GEimULAE  DISEASE  OP  THE  KIDNEY.  95 1 


the  striated  texture.  The  change  most  usual  in  this  class  of  cases 
is  buflP-orange,  or  tile-red ; but  in  some  instances  it  is  so  light  as  to 
be  of  a straw-colom’  or  sienna-yellow. 

6.  In  all  the  cases  now  mentioned,  the  transformation  either  af- 
fects chiefly,  or  is  confined  wholly,  to  the  cortical  matter  of  the 
gland.  In  a small  proportion  of  cases,  however,  it  either  affects 
first  and  mostly  the  tubular  portion  of  the  kidney,  or  it  affects  that 
after  previously  affecting  the  cortical  portion.  In  either  case,  it 
renders  the  tubular  cones  so  affected  very  hard,  almost  cartilagi- 
nous, white  or  gray-white,  or  sienna-yellow.  The  nature  of  this 
change  and  its  effects  on  the  tubuli  are  not  known.  The  tuhuli  are 
still  pervious ; but  their  tissue  is  probably  thickened  and  indurated. 
The  cortical  matter  is  at  the  same  time  of  a buff-colour,  or  tile-red, 
or  sienna-yellow,  but  differing  in  shade  from  the  colour  of  the  tu- 
bular matter. 

In  some  of  these  varieties  of  renal  disorganization,  the  kidney 
externally  is  marked  by  fissures  so  as  to  appear  lobulated  like  the 
foetal  kidney.  It  is  uncertain  whether  this  is  the  remains  of  the 
original  foetal  structure,  or  whether  it  is  to  be  regarded  as  a return 
to  the  type  of  the  foetal  structure,  as  the  effect  of  disease. 

To  complete  the  morbid  anatomy  of  this  disease  it  is  necessary 
to  advert  to  the  state  in  which  other  organs  are  occasionally  found. 

The  subcutaneous  cellular  membrane  is  in  general  more  or  less 
infiltrated  with  serous  or  sero-albuminous  fluid. 

The  serous  membranes  often  present  marks  of  inflammation,  as 
lymph,  soft  or  firm,  purulent  fluid,  masses  of  lymph,  and  adhesions 
between  their  free  surfaces.  In  the  sub-arachnoid  tissue  of  the 
brain  serous  fluid  is  sometimes  effused.  But  the  parts  most  com- 
monly presenting  lymph  or  purulent  fluid  are  the  pleura  and  pe- 
ritoneum. In  other  instances,  sero-sanguine  fluid  alon6  is  found 
within  the  cavities  of  these  membranes.  In  several  cases  I have 
met  with  lymph  in  the  pericardium. 

The  bronchial  membrane  is  often  lined  with  puriform  mucus,  or 
muco-purulent  matter  streaked  with  blood ; and  the  other  appear- 
ances of  chronic  bronchial  inflammation  are  manifest. 

The  lungs  are  in  several  cases  affected  with  pneumonia ; being 
in  a state  of  red  or  gray  hepatization.  In  some  instances  tubercles 
and  vomicas  are  found.  In  some  there  are  the  remains  of  pulmo- 
nary apoplexy. 

In  a certain  proportion  of  cases  the  heart  is  found  hypertrophied ; 
the  mitral  and  aortic  valves  are  ossified,  and  the  apertures  contracted. 


952 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


The  intestinal  mucous  membrane  is  in  persons  who  have  present- 
ed diarrhoea  during  life,  rough,  villous,  and  vascular ; the  follicles 
of  Peyer  are  enlarged ; more  frequently  the  isolated  follicles  are 
enlarged,  prominent  or  ulcerated ; and  in  some  instances  the  isolated 
follicles  of  the  colon  are  found  the  seat  of  ulceration. 

In  a small  proportion  of  cases  the  liver  is  found  enlarged  and  its 
acini  of  a nutmeg  colour.  In  some  it  has  been  found  affected  with 
kirrhosis ; and  in  a few  with  adipescence. 

The  bladder  is  generally  much  shrunk,  and  contains  a small 
quantity  of  urine,  which  when  heated  furnishes  more  or  less  coa- 
gulable  matter,  sometimes  in  considerable  quantity. 

The  blood  generally  contains  urea. 

The  period  at  which  the  change  now  described  in  the  structure  of 
the  kidney  commences  varies  under  different  circumstances.  I have 
seen  a partial  and  limited  for m of  it  affecting  one  portion  of  the  cor ti cal 
matter  between  the  second  and  third  years.  One  specimen  I met 
with  in  a complete  form  affecting  the  whole  cortical  matter  with  the 
buff-orange  transformation,  in  a boy  between  six  and  seven  years. 

Of  its  rate  of  progress  almost  nothing  is  known.  At  first  the 
change  was  observed  mostly  in  the  kidneys  of  adults ; and  in  them 
there  were  few  or  no  means  of  ascertaining  the  exact  period  at  which 
the  disease  began.  From  various  circumstances,  however,  which 
appear  in  the  course  of  the  symptoms,  it  may  be  inferred,  that 
it  takes  some  time  before  it  seriously  impairs  the  functions  of  the 
gland,  and  that  years  may  elapse  from  the  first  commencement  of 
the  disorder  to  the  time,  when  the  change  in  structure  is  so  conside- 
rable as  to  impede  in  a vital  degree  the  function  of  the  kidney. 

Pathological  Deductions.— Regarding  the  nature  of  this 
change,  and  its  origin,  various  opinions  are  entertained.  Dr  Bright, 
who  first  directed  attention  to  this  change  in  the  structure  of  the 
kidney,  regards  it  as  a species  of  degeneration ; but  thinks  that 
there  is  in  the  kidneys  in  the  early  stage  a process  of  slow  inflam- 
mation, which  lays  the  foundation  of  their  future  change  in  struc- 
ture.* Granular  degeneration,  as  it  is  usually  found  after  death 
by  long-continued  bad  health,  with  or  without  anasarca^  Dr  Chris- 
tison  regards  as  essentially  a chronic  disease ; but  allows  that, 
when  the  kidneys  are  dark-coloured,  flabby,  and  enlarged,  in  con- 
nection with  coagulable  urine  and  eventual  suppression,  they  may 
have  been  in  the  state  of  ordinary  inflammation ; {nej>hritis.\)  It  is 

* Reports  of  Medical  Cases,  Vol.  i.  London,  1827,  p.  72. 

t On  Granular  Degeneration  of  the  Kidneys,  p.  10  and  11. 


STEATOSIS  OR  GRANULAR  DISEASE  OF  THE  KIDNEY.  953 


also  to  be  observed,  that  while  several  of  the  appearances  found  in 
the  kidneys  after  death  denote  unusual  congestion  of  the  cortical 
matter,  in  the  early  stage  the  symptoms  of  pain  and  weight  in  the 
region  of  the  loins,  dryness  of  the  skin,  and  thirst,  indicate  the  pre- 
sence of  a febrile  or  inflammatory  state  of  the  system. 

M.  Martin  Solon  regards  the  disease  as  a hyperemic,  that  is,  a 
congestive  inflammatory  state  of  the  kidneys,  consequent  on  irrita- 
tion of  their  vessels  from  the  use  of  stimulating  drinks ; and  to  this 
hyperemic  state  he  ascribes  all  the  early  symptoms,  and  the  sero- 
albuminous  state  of  the  urine.*  The  granular  interstitial  de- 
posit, and  the  yellow  degeneration,  he  considers  as  the  eflfect  or 
remote  consequence  of  the  previous  hyperemic  state,  for  this  reason, 
that  the  marks  of  hyperemia  are  still  found  associated  with  the  yel- 
low degeneration.  In  some  other  passages  of  his  work,  however, 
he  questions  the  necessary  presence  of  inflammation  in  the  disease. 

M.  Rayer,  entertaining  no  doubt  of  the  inflammatory  nature  of 
the  disease,  applies  to  it  the  name  of  nephritis  albuminosa^  and  dis- 
tinguishes it  into  two  varieties,  the  acute  and  chronic.  He  is  in- 
deed the  most  decided  and  confident  advocate  for  the  inflammatory 
nature  of  the  disease  that  has  yet  appeared ; and  his  views  have  been 
espoused,  explained,  and  defended  by  his  pupil,  M.  Littre.  The 
chief  grounds  on  which  M.  Rayer  maintains  the  inflammatory  na- 
ture of  the  fawn-coloured  degeneration  of  the  kidney  are,  the  vas- 
cular redness  of  the  gland  in  the  early  stage  of  the  distemper,  the 
enlargement  or  swelling  of  the  gland,  the  occasional  presence  of 
pain,  and  the  general  presence  of  feverishness ; and  at  a later  period 
the  presence  of  vascular  spots  and  patches,  with  the  grayish  or  gray- 
yellow  granular  deposit.  He  is  also  of  opinion,  that  the  red  points 
and  spots  seen  in  the  substance  of  the  kidney  in  the  early  stage  of 
the  distemper,  (first  form  of  M.  Rayer,)  in  general  correspond  to 
the  glandules  of  Malpighi,  greatly  injected  with  blood. 

Dr  Gulliver  showed  in  1843,  that  in  kidneys  affected  by  this 
disease,  fatty  globules  and  crystalline  plates  of  cholesterine  can 
be  seen  by  the  microscope ; while  Dr  Davy  obtained  from  them 
margarine,  cholesterine,  and  a trace  of  oleine.f 

Gluge  maintains,  from  microscopical  examination  of  kidneys  in 
this  state,  that  the  infiltrated  matter  is  in  general  oil  or  fat. 

In  the  first  form,  which  is  that  in  which  the  surface  of  the  kidney 
is  yellowish  with  red  points  and  millet-seed-like  granulations,  in- 

* De  rAlbumiiiurie,  &c.  p.  258. 

-f-  Edinburgh  Medical  and  Surgical  Journal,  vol.  Lx.  p.  162.  Edinburgh,  1843. 


954 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


flammation,  with  inflammatory  globules  and  purulent  matter,  is  as- 
sociated with  fatty  infiltration  or  steatosis.  The  tuhuli,  especially 
those  of  the  cortical  substance,  are  filled  with  fat  globules  large  and 
small.  These  distend  the  tubuli,  the  convolutions  of  which  form 
the  granulations,  and  afterwards  appear  more  in  the  medullary 
(straight  tubular)  substance.  At  length  the  fat  globules  are  ef- 
fused between  the  tubuli.^  and  form  masses  of  10,  15,  or  more  fat- 
globules,  which  are  occasionally  enclosed  within  a membrane. 
The  Malpighian  bodies  and  the  capillary  vessels  are  at  first  filled 
with  blood ; but  in  the  further  progress  of  the  disease  they  are 
bloodless  and  pale.  The  vessels  of  the  medullary  substance  undergo 
a like  change,  though  to  a smaller  degree.  Not  unfrequently  the 
membrane  of  the  tubuli  entirely  disappears.  The  fat  globules  ob- 
serve in  their  mode  of  deposition  at  first  the  direction  of  these  tu- 
buli; afterwards  this  is  lost,  and  a confused  mass  of  fat-globules 
takes  their  place.  In  rare  instances  the  fat-globules  are  deposited 
not  at  first  in  the  tubuli,  but  in  the  blood-vessels  and  Malpighian 
bodies. 

In  the  second  form,  in  which  the  kidneys  are  red-brown  in  their 
cortical  as  well  as  in  their  medullary  substance,  and  in  which,  in  con- 
sequence of  a reddish  striated  arrangement  of  the  medullary,  the 
two  portions  can  scarcely  be  distinguished.  The  renal  substance 
is  recognized  as  a reddish,  soft,  almost  soluble,  jelly-like  matter, 
in  which  only  the  cellular  frame-work  with  wide  meshes  appears 
as  a separate  solid  element ; no  trace  of  tubules  or  blood-vessels 
is  to  be  found  either  in  the  cortical  or  medullary  matter ; and  fat 
globules,  scattered  among  tubules  and  empty  colourless  Malpig- 
hian bodies,  lie  in  the  residual  cellular  texture  of  the  glands. 

In  the  third  form,  in  which  the  outline  of  the  kidneys  remains 
unchanged  or  diminished,  and  their  outer  surface  and  the  section 
of  the  cortical  substance  is  occupied  with  prominent  pisiform  gra- 
nulations, giving  the  glands  a rough  aspect  and  hardish  appear- 
ance ; sometimes  inflammatory  globules  are  found  with  fat-globules ; 
yet  these  are  always  in  smaller  proportion  ; the  granulations  con- 
tain many  urinary  tubules  dilated  by  a yellowish  granular  mass 
and  fat-globules,  which  are  also  deposited  between  the  tubules. 

In  short,  the  fat  globules  may  be  deposited  within  the  tubules, 
without  them,  and  between  them,  and  without  or  around  the  Mal- 
pighian bodies.* 

According  to  Vogel,  the  cortical  substance  in  one  form  of  the 

* Atlas  der  Pathologischen  Anatomic.  Stearose  der  Niere,  Taf.  3. 


STEATOSIS  OR  GRANULAR  DISEASE  OF  THE  KIDNEY.  955 


disease,  which  is  the  inflammatory,  is  thick,  white-yellowish,  varie- 
gated with  red  dots  and  lines,  and  very  compact  like  lard.  The 
substance  contains  little  blood.  The  vessels  of  the  Malpighian 
bodies  are  much  less  distinct  than  in  the  normal  state.  The  tu- 
bules are  indistinct  and  confused,  and  between  and  around  them 
plastic  matter  is  infiltrated.  A similar  infiltration  is  observed 
among  the  medullary  tubules.* 

The  views  of  Griuge  have  been  confirmed  in  this  country  by  the 
researches  of  Dr  Johnson  and  Mr  Toynbee.  The  former  believing 
that  the  epithelial  cells  of  the  healthy  kidney  contain  a minute 
quantity  of  oil  in  the  form  of  yellowish  highly  refracting  globules, 
maintains  that  granular  kidney  consists  primarily  in  an  exaggera- 
tion of  the  fatty  matter  which  naturally  exists  in  small  quantities 
in  the  epithelial  cells  of  the  healthy  gland.  The  epithelial  cells 
of  the  tubules  may  be  in  every  degree  and  stage  of  distension  with 
fat-globules,  until  the  cell  is  so  filled  that  the  nucleus  is  no  longer 
visible.  The  Malpighian  bodies  are  the  only  parts  which  escape, 
a few  particles  only  being  scattered  over  their  interior. 

The  different  modes  and  degrees  in  which  the  fatty  deposit  takes 
place  give  rise  to  the  different  external  appearances  of  the  kidney. 
As  the  accumulation  of  fat  increases,  the  kidney  becomes  granular 
or  mottled  on  the  surface.  The  smooth  mottled  kidneys  are  those 
in  which  the  greatest  number  of  the  tubes  in  the  cortical  portion 
are  almost  uniformly  distended.  The  granular  and  atrophied  or 
small  shrunk  kidneys  are  those  in  which  the  accumulation  of  fat 
takes  place  less  rapidly  and  less  uniformly.  Some  convoluted  tubes 
become  distended  with  fat,  forming  prominent  granulations ; and 
these  compressing  surrounding  parts  produce  obliteration  of  vessels 
and  atrophy  of  tubes ; and  thus  the  entire  gland  is  wasted  and  con- 
tracted. 

Dr  Johnson  further  finds  that  granular  disease  of  the  kidney  is 
often  associated  with  fatty  disease  of  the  liver  and  the  steatomatous 
degeneration  of  the  arteries,  which  is  also  an  adipose  deposit. 
Among  22  cases  of  granular  disease  of  the  kidney  examined  in  the 
summer  of  1845,  in  17  of  these  there  was  in  a most  marked  degree 
fatty  degeneration  of  the  liver.  In  4 of  the  remaining  5 cases 
there  was  a decided  increase  of  fat  in  the  hepatic  cells ; and  in  only 
one  case  was  no  increase  observed.  During  the  same  period  Dr 
J.  met  with  only  4 cases  of  fatty  liver  in  which  there  was  no  at- 
tendant disease  of  the  kidney. 

* Jiilii  Vogel  leones  Pathologicae,  Tabula  xxvi.  p.  107. 


956 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


It  is  also  associated  with  tubei’culation  of  the  lungs,  though  in  a 
much  less  common  degree.* 

Similar  are  the  views  of  Mr  Toynbee.  In  the  first  stage  fat  be- 
gins to  be  deposited  in  the  tubules,  in  the  form  of  soft  white  spots. 
In  the  second  stage  he  represents  the  Malpighian  tufts  to  be  bro- 
ken up ; the  tuhuli  to  be  greatly  enlarged ; and  the  parenchymatous 
cells  enlarged,  and  containing  adipose  deposits ; and  in  the  third 
stage  the  tubuli  to  be  filled  with  oily  cells,  granular  matter,  par- 
ticles of  various  sizes,  and  blood-globules.f 

What  is  the  cause  of  this  fatty  infiltration  ? Is  it  an  aberration 
in  nutrition,  or  the  effect  of  a particular  form  of  inflammation. 
Though  in  favour  of  each  of  these  views  various  plausible  argu- 
ments may  be  adduced,  the  question  appears  to  be  one  incapable 
of  positive  determination.  I add  the  following  remarks,  not  so 
much  with  the  intention  of  solving  the  difficulty,  as  in  illustration 
of  the  general  question. 

It  seems  scarcely  possible  to  doubt,  that,  whether  inflammation 
be  the  cause  of  the  steatomatous  transformation  of  the  kidney  or 
not,  the  process  of  inflammation  is  often  present  as  an  accompa- 
niment. Two  views,  indeed,  may  be  taken  of  the  incipient  agent 
or  generating  cause,  and  the  nature  of  this  disease.  The  first  is, 
that  inflammation  of  a particular  form  attacking  the  cortical  por- 
tion of  the  kidney,  may  be  the  cause  of  all  the  subsequent  changes. 
The  second  is,  that  the  cortical  portion  of  the  kidney  may  be  liable 
to  an  aberration  of  nutrition,  in  consequence  of  which  its  vessels 
deposit  not  the  usual  proper  matter  of  the  cortical  portion,  but 
a different  substance  altogether,  in  the  form  of  albuminous, 
caseous  or  steatomatous  matter,  in  the  interstices  of  the'  cortical 
tissue. 

The  first  of  these  opinions,  namely,  that  inflammation  of  a pecu- 
liar kind,  most  probably  chronic,  is  the  main  cause  of  the  several 
changes,  is  perhaps  in  a large  proportion  of  cases  true.  To  the 
correctness  of  this  conclusion  it  is  not  necessary  that  the  change 
should  terminate  in  suppuration.  There  may  be,  and  we  know  that 
there  are,  different  forms  of  the  inflammatory  process ; and  it  is 
possible  that  the  cortical  or  secreting  portion  of  the  kidney  may  be 

* On  the  Minute  Anatomy  and  Pathology  of  Bright's  Diseases  of  the  Kidney,  &c. 
By  George  Johnson,  M.  D.,  Medico-Chirurgical  Transactions,  Vol.  xxix.  p.  1.  Lon- 
don, 1846. 

On  the  Intimate  Structure  of  the  Kidney,  &c.  By  Joseph  Toynbee,  F.  R.  S. 
Medico-Chirurg.  Trans.  Vol,  xxix.  p.  303. 

4 


STEATOSIS  OR  GRANULAR  DISEASE  OF  THE  KIDNEY.  957 


liable  to  a peculiar  form  of  the  inflammatory  process,  which  may 
neither  be  sufficiently  rapid  to  proceed  speedily  to  the  disorganiza- 
tion of  the  kidney,  nor  sufficiently  violent  to  evince  its  presence  by 
well-marked  symptoms.  That  the  process,  whatever  it  may  be,  is 
chronic,  may  be  inferred  from  two  circumstances.  The  first  is  the 
fact,  that  the  disease  is  often  observed  to  have  existed  for  months 
or  even  years  without  giving  rise  to  any  marked  external  symptom, 
excepting  occasional  diarrhoea,  and  sometimes  attacks  of  rheumatic 
pain  ; and  its  existence  is  never  suspected  until  some  new  symptom 
renders  it  requisite  to  examine  the  urine,  which  is  then  found  to 
contain  serous  fluid.  Rarely,  indeed,  do  patients  apply  for  assist- 
ance in  the  commencement  of  this  distemper ; and  it  is  only  when 
a train  of  long-continued  bad  health  has  prevailed  for  some  time, 
or  a smart  attack  of  acute  disease  has  come  on,  that  the  case  be- 
comes known  in  its  true  characters.  The  second  circumstance, 
showing  the  disease  to  be  most  commonly  chronic,  is,  that  when  its 
true  characters  have  bicome  known  by  various  unequivocal  symp- 
toms, it  does  not  proceed  very  rapidly  to  the  fatal  termination. 
Some  patients  remain  under  the  dropsical  symptoms  even  for 
months,  and  eventually  recover  from  them,  though  the  primary 
disease  may  not  be  cured. 

That  the  process  is  of  the  nature  of  vascular  injection,  afflux,  and 
inflammation,  seems  to  be  highly  probable,  from  the  following  cir- 
cumstances. The  appearances  in  the  kidneys  are  analogous  if  not 
similar  to  those  which  are  found  in  other  glandular  organs  when 
the  seat  of  the  congestive  and  inflammatory  process.  The  dark- 
brown  colour,  the  increased  size,  and  the  loaded  state  of  the  vas- 
cular system  of  the  renal  cortical  matter  in  the  early  stage,  are  suf- 
ficiently indicative  of  a congestive  state  to  justify  the  inference,  that 
the  cortical  tissue  is  unduly  loaded  with  hlood,  which,  as  in  all  con- 
gested and  inflamed  organs,  moves  at  first  slowly,  next  accumulates, 
and  then  stagnates  in  the  vessels.  In  those  stages,  which  may  be 
placed  after  the  very  first,  the  vascular  pits  on  the  surface  of  the 
kidney,  with  the  asteroid  clusters  of  vessels,  if  not  to  be  regarded 
as  indicative  of  an  inflammatory  process,  show  a great  derangement 
in  circulation,  which  is  caused  either  by  the  new  deposit  compres- 
sing certain  vessels,  or  hy  some  similar  obstruction.  This  process, 
nevertheless,  seems  to  be  peculiar  in  this  respect,  that  it  causes  ab- 
sorption, or  at  least  forms  hollows  in  the  cortical  portion  of  the 
gland.  The  elevations,  according  to  Dr  Johnson,  consist  each  of 


958 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


a set  of  gorged  tubules,  presenting  itself  either  at  the  surface  of  the 
gland,  or  in  its  substance  on  the  surface  of  a section. 

In  those  stages  of  the  disorder  in  which  yellowish-gray  or  fawn- 
coloured  granules  are  infiltrated  as  it  were  through  the  cortical 
substance,  it  seems  consistent  with  correct  pathology  to  ascribe  this 
infiltration  to  the  effect  of  the  inflammatory  process.  One  of  the 
most  constant  efiects  of  that  process,  if  unchecked,  is  to  give  rise  to 
morbid  products  of  albuminous,  tyromatous,  or  steatomatous  cha- 
racters ; and  it  seems  reasonable  to  regard  this  deposit,  which  is 
known  to  be  steatomatous,  as  the  effect  of  the  inflammatory  process. 

In  the  aggregated  slate-gray  granular  deposit,  the  same  views 
are  applicable.  If  the  isolated  granular  infiltration  be  the  effect 
of  inflammatory  action,  a fortiori^  the  aggregated  granular  deposi- 
tion is  the  effect  of  the  same  action.  It  appears  as  the  termination 
of  that  process,  of  which  the  others  are  earlier  and  immediate  ef- 
fects. 

One  of  the  strongest  arguments  in  favour  of  the  disease  origi- 
nating in  congestion  or  inflammation  is  found  in  the  fact,  that  it 
takes  place  after  the  operation  of  various  agents  which  act  as  re- 
mote causes  of  inflammation.  Thus  it  often  ensues  as  a sequela  of 
scarlet  fever,  especially  if  the  patient  have  been  exposed  to  cold. 
In  that  disease,  and  for  some  time  after  the  disappearance  of  the 
eruption,  the  action  of  the  skin  remains  feeble  and  languid;  and 
the  blood,  which  ought  to  circulate  through  the  cutaneous  vessels, 
is  determined  in  excessive  quantity  to  the  kidneys  and  other  inter- 
nal organs.  The  quantity  of  blood  thus  thrown  upon  the  different 
internal  organs  is  greater  than  their  vessels  can  readily  transmit ; 
these,  consequently,  become  unduly  loaded  and  distended;  and 
hence  inflammation  and  often  discharges  of  blood  take  place  at  this 
period  in  convalescents  from  scarlet  fever ; and,  among  other  in- 
dications of  this,  the  albuminous  and  occasionally  the  colouring 
matter  of  the  blood  is  forced  through  the  kidneys,  and  is  found  in 
the  urine. 

The  inflammatory  character  of  this  disease  may  be  illustrated  by 
considering  the  influence  of  another  agent  in  its  production.  No- 
thing seems  so  certainly  to  be  followed  by  the  formation  of  granu- 
lar disease  of  the  kidney  as  the  use  of  mercury  in  certain  constitu- 
tions. In  some  instances,  one  single  course  of  mercurial  medicines 
has  been  known  to  be  followed  by  the  development  of  the  disorder ; 
and  in  all  cases  in  which  repeated  courses  have  been  given,  the  dis- 


STEATOSIS  OE  GRANULAR  DISEASE  OF  THE  KIDNEY.  959 


ease  is  sooner  or  later  observed  to  ensue.  Now  it  is  to  be  observed, 
that  the  use  of  mercury  not  only  induces  an  inflammatory  state  of 
the  system,  rendering  the  blood  sizy,  and  the  individual  liable  to 
attacks  of  inflammation  in  various  organs,  hut  it  also  renders  the 
urine  serous.*  Mercury  further  acts  as  an  ii’ritant  of  the  glandular 
organs ; and  it  is  impossible  to  doubt  that  a mineral  which  we  know 
is  circulating  with  the  blood,  and  carried  to  all  the  organs,  must 
induce  in  organs  so  vascular  and  complicated  a high  degree  of 
orgasm  and  the  deposition  of  new  morbid  products. 

Another  agent,  which  operates  in  unduly  stimulating  the  kidney 
and  its  vessels,  is  the  use  of  spirituous  liquors.  It  is  well  ascertain- 
ed that  among  the  subjects  of  this  disorder  a considerable  propor- 
tion are  addicted  to  the  habitual  use  of  these  pernicious  stimulants ; 
and  as  they  are  often  taken  for  their  supposed  diuretic  properties, 
the  delusion  leads  patients  to  continue  their  use,  until  the  disease 
attains  its  confirmed  and  incurable  stage.  We  know  that  the  ha- 
bitual use  of  these  stimulants  tends  to  favour  the  formation  of  the 
steatomatous  or  fatty  degeneration  in  arteries ; and  it  seems  reason- 
able to  infer  that  their  use  is  equally  capable  of  favouring  this  de- 
position in  the  kidneys. 

Exposure  to  cold  acts  both  as  a predisponent  and  exciting  cause ; 
and  in  its  operation  causes  that  subverted  balance  in  circulation 
which  generally  precedes  congestion  and  inflammation  in  various 
internal  organs. 

It  is  probable  that  the  primary  cause,  nevertheless,  is  seated  in 
disorder  of  the  digestive  organs.  It  is  observed,  that  the  use  of 
various  indigestible  articles  of  food,  as  pastry,  is  followed  by  a se- 
rous state  of  the  urine ; and  if  a single  meal  of  this  kind  be  follow- 
ed by  such  a result,  it  is  easy  to  see  that  the  frequent  use  of  such 
articles  will  induce  a habitual  or  constant  serous  state  of  the  urine. 
It  is  manifest,  however,  that,  as  this  state  cannot  be  induced  with- 
out more  or  less  disorder  in  the  vascular  system  of  the  kidney,  the 
continued  irritation  may  give  rise  to  the  change  in  structure  which 
is  eventually  observed  in  the  kidneys  of  persons  who  have  become 
victims  of  this  disease. 

The  second  opinion,  that  the  glandular  deposit  is  the  effect  of  a 
peculiar  aberration  in  nutrition,  may  be  true  without  being  incon- 

* Observations  on  the  Dropsy  which  succeeds  Scarlet  Fever,  Art.  xv.  ; and  on  the 
Presence  of  the  Red  Matter  and  Serum  in  the  Blood  in  the  Urine  of  Dropsy  after 
Scarlet  Fever,  Art.  xviu  By  Charles  Wells,  M.  D.,  &c.  Transactions  of  a Society, 
iii.  p.  230.  London,  1812. 


960 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


sistent  with  the  presence  of  the  inflammatory  process,  either  as  a 
cause  or  as  a concomitant.  Every  aberration  in  nutrition  is  pre- 
ceded and  accompanied  with  a considerable  change  in  the  circula- 
tion of  the  part ; and  whenever  the  aberration  consists  in  the  infil- 
tration or  deposition  of  new  matter,  the  change  in  circulation  is 
similar  to,  or  the  same  with  inflammation.  This  is  seen  in  the  in- 
duration of  other  organs  as  the  lungs,  the  brain,  the  liver,  and  the 
prostate  gland.  When,  therefore,  the  granular  disease  of  the  kid- 
ney is  called  degeneration  and  transformation,  it  does  not  follow, 
that  the  ideas  thus  conveyed  exclude  the  presence  of  the  inflamma- 
tory process. 

The  urine  and  the  blood  are  much  changed  in  granular  disease 
of  the  kidney. 

The  urine  contains  less  urea  than  the  normal  proportion,  and 
always  presents  more  or  less  sero-alburainous  matter.  Its  density 
at  the  same  time  is  diminished  : and  may  vary  from  1008,  or  1010, 
or  1011  to  1115. 

The  urine  may  be  in  colour  brown,  straw-coloured,  or  reddish; 
or  it  may  be  pale  and  nearly  colourless.  Viewed  by  refracted 
light,  it  has  a peculiar  pale-blue  opalescent  tinge. 

The  serum  of  the  blood  is  less  dense  than  usual,  being  about 
1013,  and  rarely  above  1022.  The  solid  contents  are  reduced  from 
100  or  102  per  1000,  to  68,  64,  or  61  per  1000.  The  serum  in 
this  state  forms  when  heated  a loose  coagulum.  It  contains  urea, 
and  not  unusually  it  contains  more  or  less  oil ; in  which  case  it  is 
milky. 

The  proportion  of  fibrin  is  increased  in  the  early  stage.  But  as 
the  disease  advances  it  is  diminished.  The  hematosin  at  the  same 
time  is  diminished  in  quantity. 

When  the  kidneys  are  affected  with  steatosis,  it  is  observed  that 
there  is  a strong  disposition  to  the  production  of  various  inflamma- 
tory and  irritative  disorders  in  different  organs.  The  most  usual 
are  the  following. 

1.  In  the  brain  and  its  membranes.  Epileptic  and  apoplectic  symp- 
toms ; death  by  either,  or  by  stupor.  Comatose  symptoms  termi- 
nating in  death.  The  disease  named  by  various  authors  Nervous 
and  Simple  Apoplexy  is  occasionally  observed  in  persons  labouring 
under  steatosis  of  the  kidney. 

2.  In  the  chest.  Bronchitis.  Emphysema  of  the  lungs.  Pneu- 
monia and  anasarca  pulmonum ; tuberculation  and  vomicce  of  the 
lungs.  Pleurisy,  terminating  sometimes  in  empyema.  Hydrotho- 


MORBID  STATES  OF  THE  KIDNEY. — HYDATOMA. 


961 


rax.  Endocarditis^  causing  valvular  disease ; hypertrophy,  simple, 
excentric,  and  concentric ; pericarditis. 

3.  In  the  abdomen.  Spontaneous  or  irritative  vomiting,  and  va- 
rious dyspeptic  symptoms.  Diarrhoea  frequently  recurring  in  fits  ; 
and  connected  with  enlargement  of  the  agminated  or  isolated  fol- 
licles of  the  ileum.  Effusion  within  the  abdomen.  Hypertrophy  of 
the  liver,  fatty  degeneration,  and  kirrhosis. 

4.  In  the  extremities.  Anasarca.  Rheumatic  pains  and  swellings ; 
especially  synovial  rheumatism,  affecting  the  knee-joints  and  other 
articulations.  Erysipelas  of  the  face  or  extremities. 

All  these  morbid  states  are  more  or  less  dependent  on  the  mor- 
bid state  of  the  blood,  and  especially  the  presence  of  urea  in  it, 
which  acts  as  an  irritant  to  the  different  textures  and  organs. 

§ 11.  Hydatoima. — The  kidney  is  liable  to  the  formation  of  small 
watery  cysts  or  vesiculae.^  generally  of  an  ovoidal  shape,  sometimes 
roundish,  varying  in  size  from  tares  or  vetches  up  to  that  of  small 
beans.  These  bodies  appear  on  the  cortical  surface  of  the  kidney 
as  soon  as  the  outer  tunic  is  torn  off.  In  some  instances,  they  are 
few  in  number,  two,  three,  or  four  ; but  I have  seen  them  so  nu- 
merous that  it  was  impossible  to  count  them.  They  penetrate 
through  the  whole  cortical  substance  of  the  gland ; but  seldom  en- 
croach much  on  the  tubular  or  medullary  part,  which,  however, 
may  present  two  or  three  of  them. 

On  the  origin  of  these  serous  cysts  no  correct  information  has 
been  adduced.  Some  have  thought  that  they  are  degenerated  Mal- 
pighian bodies.  But  this  idea  is  totally  at  variance  with  any  thing 
hitherto  known  as  to  these  bodies.  They  may  be  enlarged  and 
dilated  portions  of  the  serpentine  tubules.  But  there  are  no  means 
of  proving  this  idea.  The  most  probable  opinion  is,  that  they  are 
mere  serous  cysts  developed  as  other  serous  cysts  in  the  cellular 
tissue  of  the  kidney.  The  cortical  matter  is  always  removed  or 
absorbed  to  make  room  for  them ; and  a kidney  affected  by  this 
disease  presents  the  aspect  of  an  immense  number  of  small  ovoidal 
cavities  excavated  in  the  cortical  portion. 

This  change  is  often  associated  with  granular  degeneration ; and 
the  urine  is  usually  albuminous. 

§ 12.  Atrophy. — This  term  is  applied  in  the  kidney  to  two  forms 
of  disease.  First; — In  steatosis  or  granular  degeneration,  after 
the  adipose  matter  has  been  infiltrated  into  the  cells  and  tubules, 
the  cortical  and  vascular  portion  of  the  kidney  becomes  shrunk  and 

3 p 


962 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


wasted.  The  kidney,  at  least  its  cortical  portion,  is,  in  short,  in  a 
state  of  atrophy. 

Secondly;  when  Nephropyema  proceeds  to  a great  extreme, 
causing  distension  of  the  calyces  and  extenuation  of  the  whole  cor- 
tical portion  of  the  kidney,  it  may  happen  that  the  greater  part  of 
the  matter  is  discharged  either  through  the  ureter  and  bladder,  or 
by  a new  opening  formed  into  the  transverse  arch  of  the  colon, 
through  that  bowel,  or  even  externally ; part  is  removed  by  ab- 
sorption ; and  the  purulent  inflammation  of  the  calycine  membrane 
ceases.  As  these  processes  advance,  the  distended  and  attenuated 
residue  of  the  kidney  contracts ; the  calyces  contract,  and  some 
may  be  united  by  mutual  adhesion  of  their  walls  and  membrane. 
Eventually  the  whole  residual  portion  of  the  kidney  is  contracted 
and  shrunk  into  a small,  flattened,  shapeless  body,  not  larger 
than  a dried  fig ; and  when  divided,  it  is  difficult  to  recognize  in 
the  remains  the  vestiges  of  the  original  structure.  The  ureter 
alone  remains,  to  prove  the  fact  that  this  body  represents  all  that 
was  a kidney.  The  pelvis  sometimes  is  left  in  a contracted  form : 
and  not  unusually  the  pelvis  and  ureter  are  obstructed  and  con- 
verted into  a solid  chord.  Some  small  traces  of  one  or  two  calyces 
remain  ; but  in  general  the  tubular  portion  of  the  kidney  is  gone, 
and  the  cortical  is  either  very  much  shrunk,  or  so  changed,  that  its 
characteristic  structure  can  no  longer  be  recognized.  This  is  atro- 
phy of  the  kidney  after  Nephropyema. 

The  lesion  is  not  common ; for  the  disease  of  which  it  is  the  se- 
quela is  usually  fatal.  I have  nevertheless  seen  three  examples  of 
it ; the  preparation  of  one  of  which  is  preserved  in  the  collection  of 
the  University.*  Job  A.  Meek’ren  records  three  instances  of  it, 
in  one  of  which  the  right  kidney  was  so  destroyed,  that  it  is  stated 
to  have  been  wanting.!  I have  already  shortly  noticed  a case  which 
occurred  to  Chomek! 

§ 13.  Hypertrophy. — The  kidney  may  be  enlarged  in  all  its 
dimensions  without  serious  change  in  its  intimate  structure.  In  the 
most  usual  case,  that  of  atrophy  of  one  kidney  after  Nephropyema, 
or  any  similar  form  of  destruction,  the  opposite  kidney  is  always 

* Notice  of  a case  of  Cyanosis  or  the  Blue  Disease,  \yith  mutual  adhesion  of  the  se- 
milunar valves  of  the  Pulmonary  Artery.  By  David  Craigie,  M.  D.  Edin.  Med.  and 
Surg.  Journal,  VoL  lx.  Case  I.  p.  268.  Edinburgh,  1843. 

Jobi  A.  Meekren,  Observationes  Medico-Chirurgicae.  Amstelodami,  1682.  Cap. 
39,  40,  and  44. 

t P.  945. 


MORBID  STATES  OF  THE  MAMMA. 


963 


much  enlarged  both  in  its  cortical  and  tubular  portion  ; its  vessels 
are  large  and  numerous ; and  little  doubt  can  be  entertained  that 
it  performs  the  functions  of  both  glands.  Such  I found  to  be  the 
state  of  the  residual  kidneys  in  the  instances  of  atrophy  already 
mentioned. 

§ 14.  Heterologous  Products. — The  kidneys  are  liable  to  be 
aflFected  by  these,  chiefly  by  enkephaloma^  and  sometimes  by  carci- 
noma. But  most  usually  they  are  involved  in  the  growth  extend- 
ing from  other  organs.  In  other  circumstances,  these  growths  in 
the  kidney  present  nothing  peculiar. 

Section  VI. 

Diseased  States  of  the  Female  Breast. 

These  are  inflammation  and  its  effects ; suppurative  induration ; 
chronic  inflammation ; lacteal  tumour ; simple  chronic  tumour  ; 
strumous  enlargement ; the  hydatomatous  tumour ; irritable  or 
neuralgic  tumour ; adipose  tumour  ; atrophy  ; hypertrophy  ; scir- 
rhus;  pancreatic  sarcoma,  and  enkephaloma. 

§ 1.  Inflammation  is  seen  sometimes  spontaneously,  more  fi’e- 
quently  as  the  eflfect  of  the  irritation  from  the  first  attempt  at  the 
secretion  of  milk.  It  usually  proceeds  to  abscess,  which,  however, 
is  seated  most  in  the  cellular  tissue  of  the  gland. 

§ 2.  Induration  is  a common  effect  of  inflammation,  and  depends 
on  the  infiltration  of  lymph  which  undergoes  coagulation,  and  on 
the  presence  of  blood  in  the  vessels,  from  which  the  lymph  is  sepa- 
rated. 

§ 3.  Strumous  enlargement  is  common  in  young  females.  Tu- 
bercular matter  or  a liquid  containing  fat  and  caseous  matter  is  in- 
filtered  within  the  tubes  and  around  them.  In  certain  cases,  after 
this  has  subsisted  some  time,  it  undergoes  an  imperfect  suppuration ; 
and  causes  a peculiar  copious  secretion  of  matter  and  abscesses  of 
the  perimastoid  cellular  tissue. 

§ 4.  Hydatoma.  Cystosarkoma  Simplex  and  Cystosarkoma 
Proliferum  of  Muller — In  the  hydatomatous  tumour,  a number  of 
serous  cysts  is  formed  in  the  breast,  which  is  generally  consolidated 
by  adhesive  inflammation.  The  cysts  may  be  only  one  or  two,  but 
are  generally  more  numerous.  In  certain  cases  they  appear  to  be 
true  hydatids  or  Acephalocysts ; and  in  others,  the  serous  cyst 
{hydatoma).  In  the  latter  case  they  are  either  a cyst  composed  of 


964 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


numerous  lamellae,  like  the  crystalline  humour,  or  they  are  a bag 
containing  serous  fluid.* 

The  cystosarhoma  is  in  short  a tumour  or  growth,  consisting  of  a 
fibrous  or  fibro-vascular  frame-work  or  stroma,  containing  cysts 
more  or  less  complete,  of  various  sizes,  and  more  or  less  numerous. 

Dr  Hodgkin  describes  a tumour  consisting  of  hydatid  cysts  as 
incident  both  to  the  female  breast  and  testis  of  the  male.f 

§ 5.  The  irritable  or  neuralgic  tumour  consists  in  painful  hai'd- 
ness  with  or  without  swelling  of  one  or  two  lobes  of  the  mamma. 
The  pain  is  disproportionate  to  the  hardness  or  enlargement.  The 
surface  is  tender,  and  does  not  bear  handling.  This  is  more  a dy- 
namic affection  than  a disease  of  the  mamma ; and  its  presence  is 
connected  with  the  state  of  the  uterus  and  ovaries.  It  occurs  in 
young  females  between  15  and  30, 

§ 6.  The  adipose  tumour  is  sometimes  an  increased  deposit  of 
the  natural  adipose  tissue  ; or  fat  may  be  deposited  in  one  or  more 
cysts.  Fatty  matter  is  also  liable  to  be  infiltrated  within  the  lac- 
teal tubules  when  the  period  of  menstruation  ceases,  causing  a sort 
of  steatosis  of  the  gland, 

§ 7,  Atrophy, — The  breasts  undergo  a species  of  shrinking  or 
atrophy  in  all  females  after  menstruation  ceases  and  the  period  of 
child-bearing  is  past.  In  some  instances,  apparently  in  connection 
with  some  morbid  state  of  the  ovaries,  one  or  both  breasts  are 
liable  to  become  shrunk  in  this  manner  previous  to  the  normal  time 
for  the  cessation  of  menstruation.  In  other  instances  fat  is  deposit- 
ed and  the  glandular  structure  diminishes  or  disappears, 

§ 8.  Hypertrophy. — In  some  females,  particularly  about  the 
age  of  18,  20,  or  between  that  and  25,  a peculiar  enlargement  of 
the  breast  is  observed.  The  gland  becomes  enlarged  and  heavy ; 
the  skin  over  it  is  likewise  enlarged.  If  the  enlargement  continue, 
the  breast  is  so  bulky  and  pendulous  that  the  tension  of  the  skin  is 
no  longer  adequate  to  support  it ; but  it  hangs  down  loose,  bulky, 
and  pendulous.  The  nipple  is  flattened ; the  areola  expanded. 
So  far  as  can  be  judged,  this  is  a true  hypertrophy  of  the  glandular 
structure. 

§ 9.  Cartilaginous  and  ossific  transformation  has  been  observed 

* Illustrations  of  the  Diseases  of  the  Breast.  By  Sir  Astley  Cooper,  Bart.  Lon- 
don, 1829.  4to. 

t On  the  Anatomical  Characters  of  some  Adventitious  Structures.  By  Thomas 
Hodgkin,  M.  D.  Medico-Chirurg.  Transactions,  Vol,  xv.  London,  1829. 


MORBID  STATES  OF  THE  MAIkBIA SKIRRHUS. 


965 


in  the  breast.  The  change  is  most  likely  confined  to  the  galacto- 
phorous  tubes. 

§ 10.  Skirrhus. — In  no  organ  has  skirrhous  structure  been  more 
frequently  studied  than  in  the  mamma.  Yet  information  is  not 
very  precise  and  presents  several  discordant  points, 

a.  It  seems  certain  that  diflferent  forms  even  of  morbid  structure 
belonging  to  skirrhus  may  affect  the  breast.  In  one  set  of  cases, 
the  gland  is  affected  with  hardness  in  lumps  or  masses,  to  which 
the  skin  is  drawn  down  in  a shrivelled  corrugated  manner,  and  ad- 
heres over  various  points  of  the  surface.  Internally,  white,  firm, 
fibrous  lines  are  seen  intersecting  each  other  through  the  gland; 
and  within  these  is  deposited  a softer  gray-coloured  matter,  which 
presents  numerous  minute  irregular  cells  and  granules,  from  the 
surface  of  which  oozes  a serous  fluid.  The  nipple  is  retracted 
and  introverted. 

In  one  of  these  tumours  of  the  breast  Vogel  found  the  two  ele- 
ments now  mentioned  united  in  the  following  manner.  In  the 
centre  or  middle  of  the  tumour  were  longitudinal  bands  apparently 
cylindrical,  thick  at  middle,  but  pointed  at  each  end,  not  straight, 
but  slightly  contorted.  These  were  crowded  very  closely  in  the 
centre ; but  at  the  margin  where  their  pointed  extremities  terminat- 
ed, they  were  more  apart.  In  the  interstices  between  these  firm 
longitudinal  chords  were  deposited  granules  spherical,  spheroidal, 
or  pyriform,  which  were  cellular,  and  had  nuclei  and  nucleoli.  Be- 
sides these,  were  very  minute  granules,  which  seemed  to  be  fat.* 

b.  In  another  set  of  cases  the  same  matter  is  deposited  in  a tuber- 
cular form,  and  assuming  the  appearance  of  irregular  masses  of 
reddish-gray  coloured  hardish  tubercles  aggregated  together,  giving 
the  whole  the  aspect  of  the  pancreas. 

According  to  Muller,  the  gray  structure  of  simple  scirrhus  of 
the  breast  bears  only  a remote  resemblance  to  cartilage.  Whitish 
chords  are  not  regularly  observed.  Skirrhus  of  the  mamma  pre- 
sents sometimes  at  various  points  fibres,  in  which  may  be  recognized 
a canal,  containing  a colourless,  or  whitish,  or  yellowish  content. 
These  white  fibres  may  be  formed  from  the  thickened  walls  of  the 
milk-tubes  and  lymphatic  vessels.  In  skirrhus  of  parts  not  glandu- 

* Julii  Vogel  leones  Histologise  Pathologic®.  Tabula  xxt.  Lipsi®,  1843. 

The  above  description  was  written  from  personal  examination  of  a number  of  skir- 
rhous mamm®  long  before  the  engravings  of  J.  Vogel  were  published.  The  only  point 
deserving  notice  is,  that  they  correspond  as  accurately  as  can  be  expected.  I refer  to 
the  engraving  of  Vogel  because  it  illustrates  the  subject  well. 


966 


GENERAL  AND  rATHOLOGICAL  ANATOMY. 


lar,  these  hollow  white  lines  are  not  observed.  The  mass  of  the 
skirrhus  consists  of  a fibrous  and  granular  gray  substance.  The 
fibrous  mass  is  rarely  manifest  on  section  ; but  it  is  distinguished  by 
scraping  the  gray  mass,  for  which  the  fibrous  seems  the  frame-work. 
When  the  gray  globular  mass  is  removed  by  scraping  or  macera- 
tion, the  fibrous  framework  appears  to  be  a very  irregular  network  of 
solid  fibrous  bundles.  The  gray  matter,  which  is  easily  removed 
from  this  framework  by  scraping,  consists  entirely  of  microscopical 
globules,  which  have  little  mutual  connection.  They  are  trans- 
parent, hollow  cells  or  vesiculae^  varying  from  looooo  to  loo^^ooj 
®od  10  0^0*0  0 of  a Paris  inch  in  diameter.  They  are  insoluble  in 
vinegar  and  water  cold  and  boiling.  In  many  of  these  cells  are 
seen  only  some  punctula  or  dots  like  small  granules ; in  others 
may  be  recognized  a larger  corpuscle  like  a nucleus,  or  like  a 
smaller  vesicula  contained  within  a cell-globule.  After  examining 
many  scirrhous  mammae,  Muller  could  not  satisfy  himself  of  the 
existence  of  small  or  young  cellules  in  the  formation-globules ; yet 
these  he  saw  evidently  in  some.* 

c.  A form  of  cancer  more  common  than  simple  scirrhus  in  the 
breast,  is,  according  to  Muller,  that  which  he  denominates  reticu- 
lar carcinoma.  This  attains  in  a shorter  time  than  simple  skirrhus  a 
large  size,  and  it  differs  from  the  latter  in  its  tendency  to  the  lobu- 
lar arrangement.  In  consistence  it  sometimes  approaches  skirrhus, 
and  sometimes  is  softer,  approaching  that  of  enkephaloma. 

Reticular  carcinoma  consists  of  a gray  globular  frame-work,  im- 
bedded in  a reticular  texture  of  fibrous  bundles,  which  is  recognized 
when  the  gray  granular  mass  is  scraped  or  macerated.  The  gray 
mass  consists  of  transparent  formation-globules  or  cell-globules, 
similar  to  those  observed  in  simple  scirrhus.  These  contain  often 
one,  two,  or  more  small  vesiculcB  with  colourless  nuclei.  In  other 
instances  the  smaller  germinal  cells  cannot  be  recognized  within 
the  larger  formation-globules.  On  the  other  hand,  in  the  interior 
of  the  transparent  cell-globules,  appear  very  many  granules.  Similar 
small  granules  are  also  observed  sometimes  in  large  quantity,  free  be- 
tween the  vesiculffi, — the  smallest  with  molecular  action.  The  colour- 
less cell-globules  have  a diameter  of  from  i.ooVooo  100,000 
10  5,000  of  one  Paris  inch.  The  diameter  of  the  enclosed  granules 
is  only  from  one-fifth  to  one-fourth  of  the  diameter  of  the  cells. 

* Ueber  den  Feinein  Ban  iind  die  Foimen  der  Krankhaften  Geschwiilste.  von  Dr  Jo- 
hannes Miiller.  Erste  Liel'eriing.  Berlin,  1 o38.  Seite  1 4. 

3 


MORBID  STATES  OF  THE  TESTIS. 


967 


This  form  of  cancer  is  distinguished  by  tlie  peculiarity  of  the 
constant  white  or  whitish-yellow  reticulated  figures  being  more  or 
less  manifest.  These  figures  are  irregularly  net-like,  sometimes 
branched  or  spotted.  There  are  no  dilated  vessels  with  thickened 
walls  as  are  sometimes  seen  in  simple  carcinoma,  but  characteristic 
formation.  The  reticulated  figures  arise  from  the  deposition  of 
white  granules  in  the  gray  mass.  These  granules  appear  not  cel- 
lular, but  resemble  most  a conglomeration  of  opaque  granules  with 
roundish  or  elongated  corpuscles. 

Cavities  are  sometimes  formed  in  this  structure ; and  in  these  is 
enclosed  a coagulable  albuminous  matter  ; while  the  walls  are  oc- 
cupied by  whitish  bodies. 

Though  this  sort  of  cancer  is  very  common  in  the  female  breast, 
it  is  not  peculiar  to  that  organ,  being  found  also  in  other  parts. 
This  shows  that  its  presence  and  formation  are  not  necessarily  con- 
nected with  the  structure  of  the  lacteal  glands.* 

d.  The  female  mamma  is  further  liable  to  be  attacked  by  enkepha- 
loma,  which  appears  with  its  usual  characters.  It  forms,  however, 
a softer  and  more  compressible  tumour ; and  it  appears  more  lobu- 
lated ; and  some  of  these  lobules  seen  to  be  cysts  containing  fluid. 
It  appears  also  in  younger  subjects ; and  is  more  a disease  of  early 
life  than  scirrhus. 

This  disease,  however,  when  it  appears  in  the  mamma,  is  rarely 
confined  to  this  gland.  The  same  structure  is  usually  developed 
in  the  liver,  or  more  or  fewer  of  the  internal  organs. 

e.  The  nipple  is  liable  to  various  morbid  changes.  The  most  com- 
mon is  excessive  development  or  growth  in  its  nucleus^  which  is  at- 
tended with  pain  and  some  swelling.  Usually  it  ceases  of  its  own 
accord.  But  if  it  do  not,  it  is  liable  to  form  a small  tumour,  which 
is  said  often  to  pass  into  the  malignant  state.  This  I believe  is 
very  doubtful,  if  the  subjacent  gland  remain  sound.  Other  morbid 
conditions  are  atrophy,  hypertrophy,  or  excessive  nutrition,  tuber- 
cular skirrhus,  and  enkephaloma. 

Section  VII. 

Morbid  States  of  the  Testis. 

The  diseased  state  incident  to  the  testis  are  inflammation  and  its 
effects ; hydrocele ; suppuration  within  the  testis ; strumous  dis- 

Ueber  den  Feinern  Biiu  und  die  Formen  den  Krankhaften  Geschwiilste. 


968 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


ease ; atrophy ; hsematocele ; hydatoma  or  cystic  disease  of  the 
testis ; cystosarcoma ; fibrous  disease ; skirrhus  ; enhephaloma  ; and 
kolloma. 

§ 1 . Orchitis. — Inflammation  is  acute  or  chronic.  In  acute  in- 
flammation the  anatomical  characters  are  more  or  less  swelling  and 
enlargement ; sero-albuminous  matter  effused  within  the  tunica  va- 
ginalis ; lymph  lining  the  tunic ; the  gland  redder  and  more  vas- 
cular than  natural,  though  not  much  enlarged ; bloody  serum  in- 
filtrated into  its  parenchyma ; and  eflPusion  of  a brownish  coloured 
fluid  into  the  cellular  tissue  of  the  epididymis  and  that  connecting 
it  to  the  testis, — causing  enlargement  and  induration  of  that  body. 

Inflammation  afiects  more  frequently  the  right  testis  than  the 
left.  Among  138  cases  of  orchitis,  in  78  the  right  testis  was  af- 
fected ; in  49  the  left ; and  in  1 1 cases  both  glands. 

The  most  usual  causes  are  the  poison  of  gonorrhoea ; a blow  or 
other  violence  on  the  gland  ; urethral  irritation  ; the  previous  ex- 
istence of  mumps ; and  probably  rheumatism. 

This  process  may  leave  the  testis  a little  enlarged  and  indurated ; 
the  epididymis  much  enlarged  and  indurated ; or  eflPusion  of  fluid 
within  the  vaginal  coat  forming  hydrocele. 

§ 2.  Abscess  in  the  centre  of  the  Testis. — Suppuration  is 
not  a common  result ; but  it  may  after  some  time  ensue  ; and  then 
it  generally  appears  in  the  form  of  a collection  of  matter  within  the 
centre  of  the  testis.  This  is  not  easily  distinguished  from  chronic 
disease,  as  there  is  constant  pain,  some  induration  and  some  enlarge- 
ment. The  disease  is  liable  to  be  mistaken  for  malignant ; and  the 
testis  may  accordingly  be  removed.  But  there  is  found  only  a 
quantity  of  greenish-yellow  opaque  purulent  matter  in  a cavity  or 
cyst  in  the  centre  of  the  gland,  the  walls  of  which  are  lined  with 
lymph.  This  I have  seen  many  years  ago ; and  I find  that  the 
same  had  been  met  with  by  Sir  A.  Cooper. 

§ 3.  Obstruction  of  the  Tubuli. — One  of  the  eflPects  of  in- 
flammation, if  obstinate  and  long  continued,  is  the  eflPusion  of  sero- 
albuminous  matter  within  and  around  the  tubuli.  The  serous  part 
disappears ; the  albuminous  or  plastic  matter  remains,  filling  and 
obliterating  the  tubules,  causing  enlargement  and  induration,  and 
afterwards  if  extensive,  atrophy  of  the  testis.  When  this  eflPusion 
affects  only  a portion  of  the  tubules  it  obliterates  them  so  com- 
pletely that  they  no  longer  perform  their  functions  of  secreting 

canals  ; and  the  lymph  outside  causing  them  all  to  adhere,  the  part 

4 


MORBID  STATES  OF  THE  TESTIS. 


969 


SO  affected  is  hard,  of  a reddish  gray  colour,  sometimes  with  white 
fibrous  lines,  the  remains  of  the  tubules.  This  portion  afterwards 
shrinks,  and  is  in  the  state  of  partial  atrophy. 

§ 4.  Strumous  Disease.  Tyroma. — Chronic  inflammation  in 
the  strumous  is  an  affection  of  the  testis  not  unusual.  It  gives  rise  to 
effusion  of  tyromatous  sero-albumen  within  and  around  the  tubules, 
filling  and  obstructing  their  cavity  with  tyromatous  matter,  and 
uniting  the  whole  in  a mass  of  tubercular  matter.  The  testis  is 
more  enlarged  than  in  common  inflammation ; and  it  is  more  or 
less  irregular  and  nodulated  on  the  surface  according  to  the  irre- 
gularity of  the  agglutinated  masses  of  tubules  composing  the  gland. 

Of  this  disease  there  are  two  forms ; one  mild,  another  more  se- 
vere. In  the  former,  the  matter  deposited  is  a peculiar  yellow  ho- 
mogeneous substance,  which  when  first  formed  is  fluid  or  semifluid 
and  afterwards  acquires  consistence  and  firmness.  It  adheres 
closely  to  the  tubuli,  and  involves  them  so  completely  as  to  convert 
them  into  one  mass.  In  this  state  it  may  remain  a long  time, 
forming  merely  a much  enlarged  testis,  or  rather  a tumour  in- 
volving the  testis. 

In  this  form,  however,  it  is  liable  to  undergo  ulterior  changes. 
Portions  of  the  mass,  which  are  always  of  a low  degree  of  vitality, 
may  undergo  inflammation.  Some  of  these  become  dead  ; or  por- 
tions are  perhaps  struck  with  death  previously,  and  excite  the  vital 
parts  to  reaction.  Sloughing  and  suppuration  proceed,  until  con- 
siderable portions  of  the  new  mass  are  ejected  ; and  if  the  patient’s 
general  strength  is  adequate  to  endure  all  this  process,  the  parts 
eventually  heal  after  the  separation  of  the  greater  part  or  the  whole 
of  the  new  growth,  which  generally  involves  the  original  tubular 
structure  of  the  testis. 

In  another  form  of  this  disease,  the  matter  deposited  contains  a 
large  proportion  or  consists  wholly  of  tubercular  matter.  This 
tubercular  matter  possesses  a degree  of  vitality  still  lower  than  the 
last,  and  more  readily  passes  into  disorganizing  processes.  Strumous 
abscesses  are  formed  at  the  surface,  or  in  the  substance  of  the  new 
growth  ; and  terminate  in  fistulae  and  sinuses.  Some  parts  become 
dead,  and  these  slough  away  as  in  the  former  case.  The  pro- 
cess, however,  is  more  enfeebling,  whether  from  its  natural  vio- 
lence or  the  weakness  of  the  constitutions  of  those  in  whom  it  takes 
place.  Many  patients  die  under  the  process. 

The  main  cause  of  the  sloughing  in  this  form  of  disease  appears 


970 


GENERAL  AND  PATHOLOGICAL  ANATOBIT. 


to  be  the  dense  and  unyielding  nature  of  the  iunica  albuginea  and 
its  processes,  and  the  tension  with  which  it  encloses  the  testicular 
tubes,  in  consequence  of  the  constriction  by  which,  when  new  mat- 
ter is  infiltrated  into  the  tubiilar  structure,  as  no  adequate  expan- 
sion takes  place,  the  enclosed  parts  are,  as  it  were,  strangulated  and 
deprived  of  vitality  by  the  compression  of  their  blood-vessels  by  the 
tunica  albuginea. 

§ 5.  Atrophy. — Under  this  head  are  comprehended  arrest  of 
development  and  wasting. 

a.  Arrest.  Most  commonly  the  testis  has  not  descended  from  the 
abdomen ; and  when  it  has,  one  or  both  are  smaller  than  usual, 
shrunk,  and  manifestly  not  adequately  nourished.  The  tubular 
portion  is  imperfectly  developed. 

b.  Wasting.  When  the  testis  has  been  fully  developed,  it  may 
be  attacked  by  wasting.  Either  after  a blpw,  contusion,  or  other 
violence,  or  sometimes,  as  was  observed  in  the  soldiers  of  the  French 
army  in  Egypt,  after  sexual  excesses,  the  testis  becomes  at  first  a 
little  larger,  then  softer  than  natural,  then  small  and  shrunk.  In 
this  form  of  atrophy,  the  tubules  undergo  a species  of  chronic  in- 
flammation, causing  obliteration  from  infiltration  of  lymph,  and 
sometimes  of  oily  matter.  The  secreting  structure  is  thus  disor- 
ganized. The  blood-vessels  shrink,  and  less  blood  than  usual  is 
conveyed  to  the  gland. 

In  a testicle  affected  by  wasting,  the  testis  feel  soft ; and  its  tex- 
ture is  pale  and  with  few  blood-vessels.  The  fluid  expressed  from 
the  tubuli  is  void  of  spermatozoa.  Mr  Gulliver  found  fatty  matter 
in  the  glandular  substance. 

§ 6.  Haematocele  ; or  effusion  of  blood  takes  place  most 
usually  within  the  tunica  vaginalis,  constituting  the  affection  called 
Haematorchis,  already  noticed. 

§ 7.  Fibrous  transformation.  Desmosis. — In  some  instances, 
not  very  common,  the  testis  has  been  found  converted  into  a spe- 
cies of  fibrous  mass ; while  its  proper  secreting  structure  has  dis- 
appeared. This  change  I regard  as  depending  on  increased  deve- 
lopment of  the  tunica  albuginea  and  its  processes,  all  of  which  be- 
come thick,  dense,  and  increased  in  size ; and  by  compressing  the 
tubular  structure  cause  its  absorption.  The  lesion  is  not  very  com- 
mon ;■  but  in  the  instances  in  which  I have  seen  it,  this  view  ap- 
])eared  to  be  directly  suggested  by  the  phenomena  and  characters 
of  the  change. 


DISEASED  STATES  OF  THE  EROSTATE  GLAND. 


971 


§ 8.  Ossification  is  probably  always  to  be  traced  to  the  tunica 
albuginea.  Patches  of  bone  appear  in  this  and  in  its  processes. 

§ 9.  Hydatoma.  Cysto-sarkoma. — The  testis  resembles  the 
female  mamma  in  the  frequency  with  which  this  growth  is  formed 
in  its  substance.  Cysts,  similar  to  hydatids,  one,  two,  or  several  in 
number,  sometimes  many,  are  formed  in  the  parenchyma  of  the 
gland.  These  may  be  so  numerous  as  to  occupy  the  w'hole  body  of 
the  testis,  the  natural  structure  of  which  is  displaced  and  disappears. 

The  nature  and  origin  of  this  disease  is  imperfectly  known.  Sir 
Astley  Cooper  was  inclined  to  regard  it  as  formed  from  enlarged 
and  obstructed  seminiferous  tubes,  because  they  are  not  distinct 
bags,  but  send  out  solid  processes  by  which  they  are  connected  with 
other  bags.  Dr  Hodgkin  regards  them  as  serous  cysts  formed  in 
the  substance  of  the  gland.  It  must  be  allowed  that  the  cysts  are 
rarely  so  large  as  in  the  breast ; and  it  is  quite  possible  that  this 
lesion  of  the  testis  may  be  different  from  the  hydatoma  of  the  breast. 

It  merely  remains  to  be  observed,  that  cysts  of  the  kind  now  de- 
scribed seem  common  to  the  kidney,  the  mamma,  and  the  testis. 

§ 10.  Of  the  Heterologous  Growths,  both  skirrhus  and  en- 
kephaloma  are  observed  in  the  testis.  It  is  difficult  to  say  which  of 
these  two  is  the  most  common.  Skirrhus  occurs,  as  in  other  or- 
gans, rather  at  a late  period  of  life.  Enkephaloma  may  take  place 
at  any  age,  but  shows  a preference  for  the  early  period,  that  is, 
before  40.  A character  of  distinction  more  important  is  that,  when 
enkephaloma  appears  in  the  testis,  the  same  structure  is  generally 
found  in  the  abdomen. 

The  anatomical  characters  of  both  are  similar  to  those  in  other 
organs. 

§ 11.  Colloid  or  Gelatiniform  cancer  takes  place  in  the 
testis ; but  much  more  rarely  than  the  other  two  lesions  now  men- 
tioned, and  infinitely  more  seldom  in  the  testis  than  in  the  stomach 
and  some  other  organs. 

§ 12.  Melanoma  also  occurs,  but  not  very  frequently,  unless  at 
the  same  time  at  which  it  appears  in  the  abdomen. 

Section  VHI. 

Diseased  States  of  the  Prostate  Gland. 

The  principal  morbid  states  of  the  prostate  gland  are  suppura- 
tion within  the  ducts ; chronic  enlargement  or  hypertrophy  of  the 
gland  and  its  effects ; and  enlargement  of  the  middle  lobe. 


972 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


§ 1.  Prostatopyema. — Suppui’ation  within  the  ducts,  or  sup- 
puration of  the  mucous  membrane  of  the  ducts,  is  a disease  of  stru- 
mous character.  The  whole  mucous  membrane,  from  their  outlets 
into  the  urethra  upwards  to  their  remote  extremities,  is  inflamed, 
secretes  lymph,  and  a foul  imperfectly  formed  purulent  matter, 
which  does  not  easily  escape,  hut  remaining,  as  it  is  increased  by 
fresh  secreted  matter,  distends  and  enlarges  the  ducts  into  small  or 
middle-sized  cavdties,  with  narrow  outlets.  A prostate  gland  in  this 
state  is  large,  bulging,  and  elastic-compressible,  as  if  containing 
fluid,  and  lobulated  on  the  surface ; and  when  divided  by  incision,  it 
appears,  as  if  it  consisted  of  several  distinct  encystedabscesses.  These 
apparent  abscesses  are  formed  by  the  ducts  of  the  gland  distended 
and  enlarged  by  purulent  matter  and  lymph.  When  the  matter  is 
removed,  the  epithelial  membrane  of  the  ducts  is  observed  lined 
with  lymph,  yet  not  in  a state  of  ulceration.  The  surface  is  indeed 
unbroken. 

This  disease  may  take  place  at  any  period  of  life,  but  is  most 
common  in  strumous  subjects  between  the  ages  of  20  and  30. 

It  causes  great  disorder  of  the  general  health,  occasionally  hec- 
tic, and  peculiar  depression  of  spirits. 

§ 2.  Chronic  Enlargement  and  Hypertrophy. — This  may 
affect  either  one  lobe,  or  both,  or  part  of  both.  The  substance  of 
the  gland  is  enlarged,  firm,  and  greatly  more  crowded  with  veins 
and  arteries  than  usual.  The  veins  are  distended,  enlarged,  and 
varicose.  Blood  and  lymph  is  infiltrated  into  the  substance  of  the 
gland ; and  eventually,  if  the  process  be  not  arrested  or  stop  spon- 
taneously, either  one  or  two  abscesses  are  formed ; or  the  pros- 
tatic substance  becomes  extremely  hard,  dark*coloured,  and  almost 
cartilaginous ; while  its  original  structure  can  no  longer  be  recog- 
nized. The  substance  of  the  gland  shows  whitish  specks  and 
lines,  which  are  manifestly  lymph  effused. 

When  the  prostate  gland  is  in  this  state  it  is  liable  to  two  morbid 
actions.  One  is  a secretion  of  ropy  viscid,  almost  puriform  mucus 
from  the  ducts  of  the  gland,  and  occasionally  the  purulent  collec- 
tions  within  these  ducts  uoticed  under  the  last  head.  The  other  is 
a discharge  of  blood  from  the  vessels  of  the  gland  more  or  less 
copious.  The  latter  is  caused  by  the  previous  distended  state  of 
the  vessels,  and  the  pressure  exerted  on  them  by  the  enlarged  and 
condensed  parenchyma  of  the  gland. 

Similar  enlargement  may  affect  the  third  lobe  of  the  prostate 
gland. 


BOOK  VI. 

THE  LUNGS  AND  HEART. 

CHAPTER  I. 

The  Lungs. 

Section  I. 

The  Minute  Structure  of  the  Sound  Lung. 

The  lungs  may  be  regarded  as  the  ramifications  and  terminal  ends 
of  the  bronchial  tubes,  pulmonary  artery,  and  pulmonary  veins,  all 
united  by  filamentous-cellular  tissue  and  enclosed  within  the  pleura. 

The  filamentous-cellular  tissue  now  mentioned  forms  with  these 
enclosed  textures  the  pulmonic  substance,  tissue,  or  parenchyma. 

The  main  point,  however,  which  it  is  important  to  know,  in 
order  to  understand  either  the  structure  of  the  lungs,  as  explana- 
tory of  their  morbid  condition,  or  the  functions  of  these  organs 
during  health,  is  the  mode  in  which  the  bronchial  tubes  are  distri- 
buted and  terminate. 

This  point  has  been  partly  considered  already,  when  speaking 
of  the  ultimate  termination  of  the  bronchial  mucous  membrane.  A 
few  points  I have  here  to  add,  in  consequence  of  the  question  of 
these  terminations  having  been  again  made  the  subject  of  research. 

Malpighi,  who  first  studied  the  structure  of  the  lungs  with 
attention,  maintained  that  the  bronchi  terminate  in  closed  ends, 
slightly  expanded  into  the  form  of  spherical  or  globular  vesiculae 
{vesiculae  orbiculares),  which  he  in  one  passage  compares  to  the 
cells  of  bee-hives.*  This  shows  that  he  believed'  that  these  vesiculae 
communicate  with  each  other.  He  thought  it  also  probable  that 
these  vesiculae  are  continuations  or  processes  from  the  inner  mem- 
brane of  the  windpipe,' — in  other  words,  from  the  bronchial  mem- 
brane. 

Duverney  maintained,  in  1699,  that  these  vesicles  or  cells  com- 
municate with  each  other;  and  Stephen  Hales,  who  examined 
them  in  the  calf  by  the  microscope,  represents  them  as  little  cubes 
or  hexaedral  figures,  not  spherical,  and  estimates  their  diameter  at 
■s  50  p3^rt  of  one  inch.f 

* De  Pulmonibus,  Epistola  I.  J.  Alphonso  Borelli.  Marcelli  Malpighi,  Opera  l 
Omnia.  Londini,  1686.  Folio.  Tomus  Secundus,  p.  133  and  134. 

+ Statical  Essays  Vol.  i.  pp.  239  and  241.  London,  1731. 


974 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Senac  next  maintained  that  the  lungs  consist  of  lobules ; that 
each  lobule  consists  of  vesiculae^  in  each  of  which  ends  a bronchial 
tube;  and  that  each  vesicida  consists  of  small  polyedral  cells, 
not  more  than  the  sixth  part  of  one  line  in  diameter. 

This  idea  of  vesicles  or  small  cells. was  adopted  by  James  Keill, 
Cheselden,* * * §  Winslow, f and  various  systematic  authors ; and  the 
idea  of  Duverney  that  they  communicate,  appears  at  the  same  time 
to  have  been  added. 

Helvetius  on  the  other  hand  was  of  opinion,  from  various  exa- 
minations and  experiments,  that  the  representation  of  round  vesi- 
cul(2  or  cells  was  entirely  a fiction  ; that  what  Malpighi  describes 
as  air  vesicles  are  the  cells  of  the  cellular  tissue ; and  that  the 
closed  ends  of  the  bronchial  tubes  are  the  last  recipients  of  the  at- 
mospheric air.J 

Haller,  though  inclined  to  the  doctrine  of  Helvetius,  inferred 
nevertheless,  that  considering  all  the  circumstances  and  the  pheno- 
mena of  experiments  and  dissections  in  living  or  recently  dead 
adult  animals,  each  bronchial  tube  does  not  terminate  in  an  in- 
dividual cavity,  but  that  there  is  in  the  human  as  in  the  reptile 
lung,  a cellular  arrangement,  the  imperfect  chambers  of  which 
communicate  freely  with  each  other,  until  the  investment  of  each 
lobule  delays  the  passage  of  the  air  and  prevents  it  from  proceed- 
ing from  lobule  to  lobule. 

All  these  observers  speak  in  a manner  ratber  confused  and  some- 
times contradictory  ; and,  though  it  seems  singular,  that  any  one 
accustomed  to  inquiries  of  this  kind  could  confound  the  termina- 
tions of  the  bronchial  tubes,  whether  forming  cells  or  not,  with  the 
cells  of  the  pulmonic  cellular  tissue,  there  is  reason  to  believe  that 
this  was  done  by  Dr  Hales. 

The  doctrine  of  communicating  air-cells  was  accordingly  very 
generally  taught  by  anatomists,  and  is  distinctly  presented  by 
Soemmering,  who  may  be  taken  as  the  representative  of  anatomical 

* “ They  are  each  composed  of  very  small  cells,  which  are  the  extremities  of  the 
aspera  artcria  or  hrmchos.  The  figure  of  these  cells  is  irregular,  yet  they  are  fitted 
to  each  other  so  as  to  have  common  sides  and  leave  no  void  space.” — Anatomy, 
Book  iv.  Chap.  vii.  p.  173.  Lond.  1784. 

Exposition  Anatomique  de  la  Structure  du  Corps  Humain.  Par  Jacques-Benigne 
Winslow,  de  I’Academie  R.  des  Sciences,  &c.  Paris,  1732.  4to.  N.  104  et  1 36. 

J Memoires  de  I’Academie  des  Sciences,  1718,  p.  24 — 28. 

§ Elementa  Physiologic,  Lih,  viii.  Sectio  ii.  § xxix.  § xxx.  Tom.  iii.  p.  170. 
Lausanne,  1766. 


MINUTE  STRUCTURE  OF  THE  LUNGS. 


975 


doctrine  at  the  close  of  the  18th  century,  and  for  the  first  fifth 
of  the  19th.  According  to  Soemmering  the  substance  of  the  lung 
consists  of  small  air-cells  or  vesicuM.  Several  of  these  vesiculce. 
form  a cluster,  (acervulus) ; several  clusters  compose  small  lobxJes ; 
these  unite  into  large  lobules  ; and  these  by  their  union  form  the 
lobes  of  the  lungs. 

These  cells  appear  to  be  round,  polygonal  and  irregular.  When 
inflated  they  are  about  the  eighth  or  the  tenth  part  of  one  line  in 
diameter  ; and  they  communicate  with  each  other  through  the 
wind-pipe,  in  such  manner  that  air  blown  into  one  cell  easily  passes 
from  this  into  the  bronchia,  and  by  these  penetrates  into  all  the  other 
cells  of  the  lungs.  The  cells  of  neighbouring  lobules,  however, 
do  not  communicate  with  each  other  ; and  it  is  only  the  cells  be- 
longing to  each  cluster  and  lobule  that  thus  communicate.* 

If  this  description  be  understood  literally,  it  implies  that  the  al- 
leged cells  of  the  lungs  do  not  communicate  with  each  other  by 
themselves,  but  only  by  the  arrangement  of  the  bronchial  tubes 
terminating  in  them.  From  this  it  follows,  that  these  air-cells  are 
mere  shut  ends  of  the  bronchial  tubes. 

In  1808  Reisseissen  examined  in  various  modes  the  terminal  ends 
of  the  bronchial  tubes,  and  arrived  at  the  conclusion,  that  the  lung 
possesses  no  arrangement  like  that  described  as  air-cells,  and  that 
closed  ends  of  the  bronchial  tubes,  not  communicating  with  each 
other  however,  but  which  retaining  the  peculiar  structure  to  their 
extremities,  present  the  appearance  of  air-cells  or  air-vesicles.t 

The  essay  of  Reisseissen  was  not  published  till  1822 ; and  it  was 
only  subsequent  to  that  time  that  his  statements  became  known  or 
their  correctness  ascertained. 

Magendie  examined  in  1821  the  minute  structure  of  the  lungs 
by  inflating  and  drying  small  portions ; and  concluded  that  there 
is  a cellular  or  vesicular  arrangement  at  the  extremities  of  the 
bronchial  tubes  communicating  with  these  tubes,  and  in  which  these 
tubes  finally  terminate ; that  these  cells  present  no  regular  form, 
and  appear  to  be  void  of  membranous  walls  ; that  they  are  formed 
by  the  last  divisions  of  the  pulmonary  artery,  the  radiculcB  or  roots 
of  the  pulmonary  veins,  and  the  numerous  anastomoses  of  these 
vessels ; that  all  the  cells  of  one  lobule  communicate  with  each 

* De  Fabrica  Corporis  Humani.  Tomus  sextus,  § xxi. 

-f-  Franz  Daniel  Reisseissen  iiber  den  Ban  der  Lungen.  Berlin,  1 822.  Folio  ; and 
Edinburgh  Medical  and  Surgical  Journal,  Vol.  xxi.  p.  444.  Edinburgh,  182*4. 


976 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


other,  but  not  with  those  of  contiguous  lobules;  and  that  these 
cells  vary  in  size  at  different  ages.* 

Reynaud,  who  exaniined  the  bronchial  tubes  with  the  view  of 
ascertaining  the  accuracy  of  the  representations  of  Reisseissen, 
arrives  at  the  following  conclusions. 

Any  given  bronchial  tube  when  traced  through  the  lung  is  found 
to  divide  before  and  behind,  and  on  each  side  into  small  branches  ; 
which  again  traced  still  further  are  found  to  be  subdivided  into 
branches  still  smaller  than  these.  These  divisions  become  shorter 
and  shorter,  and  of  smaller  calibre,  end  in  becoming  rounded,  as 
if  they  had  formed  at  their  side  a number  of  small  shut  ends  or  de- 
pressions, and  at  length  they  terminate  in  an  extremity  shut  and 
scarcely  enlarged.  This  is  shown  by  mercury  poured  into  them 
and  urged  forward  by  pressure,  when  the  mercury  demonstrates,  as 
it  were,  the  last  divisions  of  the  diminutive  bronchial  tree, — and  also 
by  insufflation  and  dissection.;  These  small  tubes  all  terminate 
at  right  angles  to  the  pleura,  which  allows  the  observer  to  recog- 
nize only  the  assemblage  of  their  terminal  sacs,  and  not  the  bron- 
chial tubes  from  which  they  proceed. 

He  mentions,  however,  the  following  disposition  also.  A greater 
or  smaller  number  of  bronchial  tubes  larger  than  others  do  not 
end  thus  at  the  pleura ; but  having  come  near  it,  instead  of  termi- 
nating more  or  less  rectangularly  at  the  pleura,  proceed  beneath 
this  membrane  parallel  to  it,  and  terminate  at  the  distance  of  two, 
three,  four,  or  five  lines  from  their  point  of  emergence.  The  air 
which  filled  these  tubes  appeared  like  the  mercury,  in  the  instance 
above  mentioned,  to  represent  these  small  trees  with  perfect  regu- 
larity, and  to  demonstrate  their  arborescent  disposition  to  that 
point,  when  pressure  more  or  less  forcible  was  inadequate  to  urge 
the  air  onward,  and  where  it  was  evident  it  had  reached  its  last 
limits. 

These  ends  of  bronchial  tubes  are  about  two  lines  from  the 
pleura,  or  even  less ; and  to  demonstrate  them  fully,  it  is  often 
requisite  to  open  them  the  whole  length,  and  urge  a bristle  through 
them,  so  as  to  perforate  that  membrane,  or  to  make  a small  counter 
opening.  In  this  manner  the  end  of  the  bronchial  tube  is  displayed, 
showing  the  membrane  continuous  from  the  upper  part  of  the  tube 

+ Memoire  sur  la  structure  du  poumon  de  I’homme  ; sur  les  modifications  qu’ 
eprouve  cette  structure  dans  les  divers  ages  ; et  sur  la  premiere  origine  de  la  phthisic 
pulmonaire  ; par  M.  Magendie.  Journal  de  Physiologic,  Tome  i.  p.  78.  Paris,  1821. 


MINUTE  STRUCTURE  OE  THE  LUNGS. 


977 


throughout.  The  only  other  circumstance  is,  that  at  two  lines 
from  the  termination,  it  looks  as  if  perforated  by  many  small  de- 
pressions, which  it  had  not  previously  presented.  Small  apertures 
leading  into  small  ultimate  branches  are  likewise  seen  more  and 
more  near  to  each  other.* 

The  general  correctness  of  this  description  is  strongly  confirmed 
by  the  phenomena  of  obliteration  of  the  bronchial  tubes. 

Bourgery  made  known  to  the  Academy  first  in  1836,  and  after- 
wards in  1842,  the  results  of  researches  on  the  minute  structure  of 
the  lungs,  of  which  the  following  is  a summary.  To  every  minute 
lobule  of  the  lung  is  sent  one  central  bronchial  tube,  which  pro- 
ceeds to  the  peripheral  basis  of  the  lobule,  and  is  distributed  with 
progressive  ramification  to  the  terminal  ends  of  the  same.  During 
this  course,  the  central  stem  sends  within  the  lobule  alternately, 
radiating  in  all  directions,  subordinate  shoots,  Vi^hich  are  to  be  con- 
sidered as  terminal  branches  of  the  proper  air-tube  tree,  and  which 
Bourgery  denominates  ramified  bronchial  canals.  Beyond  these 
commences,  according  to  M.  Bourgery,  the  capillary  air-sucking 
system.  Each  ramified  bronchial  canal  ends  in  a small,  irregular, 
winding,  elongated  dilatation,  which  is  sometimes  two-lobuled  or 
three-lobuled.  These  are  bounded,  in  their  course  and  in  their  di- 
latations, by  walls  perforated  in  a sieve-like  fashion  by  small  orifices, 
by  which  the  branched  and  ramified  bronchial  tree,  as  an  inferent  and 
efibrent  apparatus,  is  connected  with  those  parts  of  the  lungs  which 
are  to  be  viewed  as  the  proper  functional  substance.  This  part 
forms  a labyrinth  of  tubes  expanded  in  three  directions,  which  are 
distributed  in  a tortuous  course  along  the  windings  of  the  vessels, 
observe  a proportional  diameter,  and  at  their  ends  also,  as  in  the 
lateral  walls,  communicate  with  each  other  by  many  orifices.f 

Dr  Thomas  Addison  maintains  the  existence  of  a collection  of 
cells  in  which  a filiform  bronchial  tube  terminates. 

Mr  William  Addison  gave  in  1842  an  account  of  the  results  of 
various  researches  which  he  had  made  by  the  aid  of  the  microscope, 
on  the  distribution  of  the  ends  of  the  bronchial  tubes,  and  arrived  at 
the  conclusion  that  these  tubes  do  not  end  in  closed  sacs ; and  that 
after  dividing  into  numerous  minute  branches,  which  take  their 

* Memoire  sur  I’Obliteration  des  Bronehes  ; par  A.  G.  Reynaud,  D.  M.  &c.  Me- 
moires  de  I’Academie  Royale  de  Medecine,  T.  iv.  p.  116.  Paris,  1836.  4to. 

-1-  Extrait  d’un  Memoire  sur  la  Structure  intime  des  Poumons  dans  I’homme  et  les 
Mamraiferes,  (lu  a PAcademie  des  Sciences,  11  Juillet  1 842,)  by  J.  M.  Bourgery.  Ga- 
zette Medicale,  1842,  Tom.  x.  N.  20. 

3 Q 


978 


GENERAL  AND  PATnOLOGICAL  ANATOMY. 


course  in  the  cellular  interstices  of  the  lobules,  they  terminate  in  their 
interior  in  branched  air  passages,  and  freely  communicating  air-cells. 

It  is  proper  to  premise,  that  to  each  lobule  of  the  lung  belongs 
one  bronchial  tube  of  some  size  ; that  the  divisions  or  branches  of 
this  bronchial  tube  are  confined  to  the  lobule  to  which  it  belongs, 
which  indeed  it  forms,  and  do  not  copimunicate  with  the  branches 
of  adjoining  lobules  ; and  that  each  lobule  is  enclosed  in  cellular 
or  filamentous  tissue,  firmer  than  that  within  the  lobule,  and  which 
thus  separates  that  lobule  from  the  surrounding  ones.  The  small 
bronchial  divisions  within  each  lobule  are  intralobular  ramifications. 

In  the  foetal  lung,  these  intralobular  bronchial  divisions  pursue  a 
regular  branched  arrangement,  subdividing  in  all  directions,  and 
terminating  at  the  boundary  of  the  lobule  in  closed  extremities. 
Many  also  terminate  in  the  interior  of  the  lobule.  These  intralo- 
bular branches  do  not  anastomose. 

In  the  foetal  lung,  there  are  no  air-cells  properly  speaking.  But 
when  an  animal  breathes,  the  air  entering  by  its  pressure  into  tbe 
windpipe  and  bronchial  tubes  proceeds  to  the  intralobular  brandies ; 
and  in  this  manner  distends  each  lobule  speedily  to  as  great  extent 
as  these  intralobular  branches  allow.  After  this  they  are  found  to 
form  a series  of  communicating  cells,  which  are  permanently  occu- 
pied by  air ; and  in  this  all  the  trace  of  the  original  branched  ar- 
rangement is  lost  or  obscured.  These  cells  are  pentagonal  or 
hexagonal  in  shape. 

This  may  be  regarded  as  the  statement  of  the  fact  as  given  by 
Mr  Addison.  The  cause  of  this  cellular  formation  is  twofold ; 
first,  the  forcible  pressure  of  the  air  which  enters  by  the  windpipe, 
and  is  perpetually  impelled  to  the  ultimate  extremities  of  the  tubes 
and  their  intralobular  ramifications ; and  the  delicate  and  yielding- 
membrane  of  these  ramifications,  which,  by  presenting  an  unequal 
resistance,  is  thus  distended  into  cells. 

The  air-cells  do  not,  however,  communicate  with  each  other  in 
the  interior  of  a lobule  in  an  indiscriminate  and  general  manner. 
As  the  intralobular  bronchial  ramifications  do  not  anastomose,  the 
air-cells  formed  along  one  branch  do  not  communicate  with  those 
formed  along  another ; and  so  on  through  the  whole  lobule. 

The  lobules  nevertheless  present  in  their  interior  branched  pas- 
sages forming  a communication  between  the  cells.  But  these  pas- 
sages are  stated  to  be  neither  tubular  nor  cylindrical.  They  are  de- 
nominated lobular  passages. 


3 


DISPOSITION  OF  THE  AIR-CELLS  IN  THE  LUNGS. 


979 


When  a thin  section  of  inflated  and  dried  lung  is  placed  under 
the  microscope,  a number  of  large  well-defined  oval  roRAiMrisrA, 
with  a sharp  delicate  edge,  is  seen  thickly  distributed  among  the 
cells.  These  foramina  are  portions  of  lobular  passages.  They 
are  smaller  near  the  pleura  and  surface  of  the  lung  than  in  the  in- 
terior of  the  organ. 

When  mercury  is  poured  into  the  lungs  of  a rabbit  which  have 
been  macerated,  so  as  to  expel  the  air,  it  gets  into  the  air-tubes, 
and  appears  at  the  surface  of  some  in  the  form  of  globides,  at  that 
of  others  as  beaded  and  nodulated  branches,  which,  according  to  Mr 
Addison,  combine  the  character  of  cells  and  passages. 

The  membrane  of  these  air-cells,  when  examined  by  the  micro- 
scope, does  not  form  round  or  even  rounded  cells,  but  flat  mem- 
branous plates,  circumscribing  polyhedral  spaces.  They  present 
ovate  bodies  as  part  of  their  structure.  They  possess  an  epithelium 
in  the  form  of  large,  round,  nucleated  scales,  in  each  of  which 
from  one  to  fifteen  or  more  nuclei  may  be  counted. 

IMr  Addison  found,  like  Magendie,  the  cells  in  early  life  small, 
and  in  old  age  large.  At  the  age  of  45,  they  vary  from  to 
part  of  one  inch  in  diameter.* 

The  correctness  of  these  statements  has  on  the  whole  been  con- 
firmed by  the  researches  of  Mr  George  Rainey. 

Mr  Rainey  finds  that  when  the  bronchial  tubes  have  arrived  at 
about  one-eighth  of  one  inch  from  the  surface  of  the  lung,  the 
membrane  terminates  abruptly ; that  the  passages  conveying  the 

■*  On  the  Ultimate  Distribution  of  the  Air-Passages  and  the  Air-Cells  of  the  Lungs. 
By  WiUiam  Addison,  Esq.  F.  L.  S.,  &c.  Read  7th  April  1812.  Philosophical  Trans- 
actions, London,  1842. 

On  the  use  of  the  term  vesicle,  Mr  Addison  pronounces  a criticism  which  partakes 
more  of  boldness  than  wisdom  or  knowledge.  “ Anatomical  writers,”  says  Mr  Addi- 
son, “ generally  use  the  terms  air-vesicles  and  air-cells  synonymously,  so  that  they  are 
convertible  terms  ; but,  strictly  speaking,  an  air-vesicle  is  an  air-bubble,  and  may  exist 
either  in  or  out  of  a pulmonary  air-cell.” — Phil.  Trans,  vol.  for  1843,  p.  158. 

It  is  rather  the  term  vesicles  than  air-vesicles,  that  anatomical  writers  use  as  s}tio- 
nymous  with  that  of  air-cells.  By  what  means  Mr  Addison  has  arrived  at  the  inference 
that  vesicle  means  air-bubble,  I know  not.  But,  with  deference  to  Mr  Addison,  he 
will  find  that  all  the  anatomical  writers  who  have  spoken  of  these  bodies — Malpighi, 
Senac,  Winslow,  HaUer,  and  Soemmering — employ  the  term  in  its  original  accep- 
tation, that  is,  a small  vesica,  or  bladder,  or  small  membranous  bag  or  cell.  The  words 
of  Soemmering  are  ; “ Pulmonum  substantia  parvis  celhdis,  vesiculis,  vel  sacculis  aere 
plenis  conflatur. — Plures  ejusmodi  vesiculre  in  acervulos  congeruntur.”  Tomus  sextus, 
§ xxi. — The  idea  that  the  word  vesicula  is  ever  used  to  signify  an  air-bubble  is  a mo- 
dern invention,  not  sanctioned  by  classical  use.  Bulla  is  the  word  used. 


980 


GENERAL  AND  PATHOLOGICAL  ANATOMY, 


cTir,  which  he  terms  intercellular,  continue  in  the  same  direction  as 
the  tubes  of  which  they  are  continuations,  but  without  perceptible 
membranous  lining ; that  the  diameter  of  the  ultimate  bronchial 
tubes  is  from  to  of  one  inch ; that  they  communicate  with 
but  few  cells ; that  the  intercellular  passages,  the  intralobular  of 
Mr  Addison,  are  at  first  of  a circular  form,  communicating  also 
with  few  cells ; but  as  they  approach  the  surface  of  a lobule,  their 
number  increases,  and  at  length  these  communicating  openings  are 
so  numerous  and  so  close,  that  the  intercellular  passage  loses  its 
circular  figure,  and  forms  an  irregular -shaped  passage  running  be- 
tween air-cells,  and  communicating  with  them  in  all  directions,  and 
having  arrived  at  the  surface  of  a lobule,  it  terminates  in  an  air-cell, 
which  is  not  dilated,  but  is  in  truth  of  the  same  size  as  the  passage. 

The  air-cells  are  small,  irregularly-shaped,  yet  most  frequently 
four-sided  cavities,  varying  in  size  in  different  parts  of  the  same 
lung.  Those  are  smallest,  as  well  as  most  vascular,  which  are  situ- 
ate nearest  the  centre ; while  their  size  increases,  and  their  vascu- 
larity diminishes,  as  they  extend  into  remote  parts.  The  air-cells 
situate  close  to  the  bronchial  tubes,  or  intercellular  passages,  open 
into  them  by  large  circular  apertures  ; while  those  placed  further 
from  these  passages,  communicate  with  them  through  the  medium 
of  other  cells. 

Besides  these  intervening  air-cells,  there  are  others  which  fill  the 
angle  formed  by  the  bifurcation  of  the  intercellular  passage,  and 
which  thus  appear  to  form  a communication  between  them. 

Mr  Rainey  controverts  the  statement  made  by  Mr  Addison,  that 
in  the  lungs  of  the  foetus,  the  air-cells  are  not  developed.  He  in- 
jected the  lungs  of  various  foetal  animals  which  had  never  breathed^ 
and  found,  on  examining  them  with  the  microscope,  that  the  air- 
cells  were  developed  proportionally  with  other  parts  of  the  lungs. 

He  adds,  however,  that  in  the  very  young  foetus,  the  septa,  or 
partitions  between  tbe  air-cells,  consist  almost  entirely  of  minute 
cellules  or  granules,  and  a small  quantity  of  fibrous  tissue,  with 
scarcely  any  blood-vessels ; and  that,  as  the  age  of  the  foetus  ad- 
vances, this  granular  matter  diminishes,  while  the  capillaries  in- 
crease, so  that  at  birth  the  same  arrangement  of  the  air-cells  and 
the  other  parts  of  the  lungs  is  observed  as  in  after  life. 

The  capillaries  of  the  lungs  are  situate,  or  contained  within,  a 
fold  of  membrane.  Traced  from  tbe  peripheral  to  the  central  parts, 
this  membrane  lines  first  the  air-cells  which  are  next  the  surface  of 


MORBID  STATES  OF  THE  LUNGS PNEUMONIA. 


981 


a lobule,  whether  next  the  pleura  or  adjoining  lobules ; then  the 
cells  enclosing  the  capillary  vessels ; and  thence  extending  from 
cell  to  cell,  it  arrives  at  the  intercellular  passages,  and  at  the  ter- 
mination of  the  bronchial  tubes  becomes  identified  with  the  bronchial 
membrane.* 

In  several  points  these  statements  agree ; in  others  they  greatly 
differ.  On  two  points  all  agree.  The  first  is,  that  within  each 
lobule  there  is  a separate  or  proper  system  of  minute  bronchial  ra- 
mifications, with  terminal  ends,  between  which  there  are  communi- 
cations within  the  lobule  only.  The  second  is,  that  these  bronchial 
divisions  and  terminations,  whether  named  air-cells  or  not,  do  not 
communicate  with  those  of  the  contiguous  lobules.  The  air  which 
enters  the  interior  of  one  lobule  never  can  find  its  way  into  the  in- 
terior of  the  contiguous  lobules. 


Section  II. 

Morbid  States  of  the  Lungs. 

The  morbid  states  of  the  lungs  are,  inflammation  and  its  effects  ; 
hepatization  of  various  kinds ; suppuration ; haemorrhagic  peripneu- 
mony ; gangrene ; dilatation  of  the  air-cells ; emphysema ; hemor- 
hage  ; tuberculation  and  vomicae  ; parasitical  animals,  and  various 
heterologous  growths. 

§ 1.  Pneumonia. — The  anatomical  characters  and  morbid 
effects  of  inflamed  lung  may  be  stated  in  the  following  manner. 
Isi,  On  opening  the  chest  and  admitting  the  air,  though  there  are 
no  adhesions,  the  lung  does  not  collapse  at  all,  or  does  so  very 
slightly.  2cf,  The  pulmonic  substance,  when  inflamed,  becomes 
harder  and  denser  than  natural,  and  does  not  float  completely  in 
water.  If  the  induration  is  considerable  or  extensive,  it  sinks  en- 
tirely. 3c?,  It  loses  its  elasticity  and  compressibility,  or  cannot  be 
inflated,  and  no  longer  crepitates  as  in  the  healthy  state,  but  re- 
sembles a piece  of  solid  flesh.  4:th,  When  divided  by  the  knife,  a 
portion  of  inflamed  lung  is  more  or  less  firm ; its  spongy  or  vesicu- 
lar structure  appears  much  redder  than  usual,  the  colour  being 
chiefly  florid  but  partly  of  a darker  hue  ; a white  or  yellowish  fluid, 
somewhat  frothy,  flows  from  the  cut  bronchial  tubes ; the  substance 
of  the  lung  is  dark  red  or  brown-red,  and  very  much  loaded  with 

* On  the  Minute  Structure  of  the  Lungs,  and  on  the  Formation  of  Pulmonary  Tu- 
bercle. By  George  Rainey,  Esq.  M.  R.  C.  S.  Medico-Chirurgical  Transactions,  vol, 
xxviii.  p.  581.  London,  1845. 


982 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


blood  within  vessels  and  out  of  them  ; while  bloody  serum  escapes 
copiously  from  the  proper  pulmonic  cellular  tissue. 

These  may  be  regarded  as  the  general  characters  of  inflamed 
lung.  These  characters  nevertheless  vary  according  to  the  pro- 
gress of  the  disease  ; and  it  is  observed,  that  a lung  in  a state  of 
inflammation  presents  different  characters,  as  that  inflammation  is 
in  its  commencement,  is  established,  is  completed,  or  is  subsiding. 

Laennec  describes  three  different  degrees  of  pneumonic  inflamma- 
tion, and  distinguishes  them;  according  as  the  lung  is  red  or  vio- 
let, but  crepitates  and  discharges,  when  cut,  a frothy  blood-coloured 
fluid ; the  stage  of  obstruction  ; 2d,  as  the  portion  of  lung  is  destitute 
of  crepitation,  and  is  red  and  granulated  interiorly,  without  discharge 
of  fluid  when  cut,  unless  squeezed ; the  stage  of  hepatization  or 
carnification  ; 2>d,  as  it  is  consistent  and  granular,  its  section  a pale 
yellow,  a straw  or  stone-gray  colour,  and  as  it  discharges  a consi- 
derable quantity  of  opaque,  yellowish,  viscid  fluid,  from  many  points 
of  its  cut  surface ; — the  stage  of  gray  hepatization  or  purulent  in- 
filtration. In  this  state  the  substance  of  the  lung  is  friable  and 
lacerable,  and  easily  gives  way. 

I think  four  different  stages  may  be  recognized,  exclusive  of  ef- 
fects. 

In  the  first,  the  lung  is  dark  red,  or  reddish-brown,  or  violet- 
coloured,  and  does  not  collapse  when  the  chest  is  opened.  It  feels 
also  slightly  more  firm  and  resisting,  but  not  so  much  as  in  the 
next  stage.  When  cut,  it  is  observed  to  be  loaded  with  blood, 
which  is  very  abundant  in  the  filaraento-cellular  tissue  ; much  blood 
and  bloody  serum  escapes ; frothy  serous  fluid  also  is  observed  to 
issue  from  divided  bronchial  tubes.  The  lung  still  crepitates,  but 
is  slightly  cedematous,  or  at  least  receives  the  impression  of  the  finger. 

When  a lung  in  this  state  is  examined  by  the  microscope,  no 
morbid  product  is  seen  in  the  filamento-cellular  tissue.  The  ves- 
sels, that  is,  the  capillaries,  are  injected  and  loaded  with  fluid  blood, 
generally  dark  coloured,  and  with  serum.  The  air-cells,  or  at 
least  the  small  divisions  of  the  bronchial  tubes,  are  filled  with  serum 
mixed  with  air.  This  is  the  stage  of  injection  or  bloody  congestion, 
and  it  affects  the  capillary  vessels,  the  filamento-cellular  tissue,  and 
the  air-cells  of  the  lungs.  It  is  therefore  pneumonia  with  vesicular 
bronchitis. 

This  state  of  lung  may  affect  one  or  both  lungs.  When  it  af- 
fects both,  it  often  proves  fatal,  from  the  great  extent,  not  the  in- 


MORBID  STATES  OF  THE  LUNGS. — PNEUMONIA. 


983 


tensity  of  the  lesion.  In  cases  in  which  it  affects  only  one  lung,  or 
part  of  one,  or  part  of  both,  recovery  is  more  easily  effected. 

In  the  second  stage,  the  lung  is  a little  firmer  and  more  resistent, 
and  may  project  beyond  the  ribs  when  the  chest  is  opened.  It  is 
more  thoroughly  loaded  with  blood ; and  blood  begins  to  be  sepa- 
rated into  h\oodi-plasma  {liquor  sangumis),  and  serum,  in  being 
effused  into  the  filamento-cellular  tissue.  The  blood  is  sometimes 
found  infiltrated  extensively  into  the  lower  part  of  the  lung,  and  is 
not  separated  decidedly  into  lymph  or  clot  and  serum.  Its  pre- 
sence, however,  renders  the  lung  dark-red  or  brown,  massy,  and 
consistent ; yet  it  crepitates  in  various  parts ; and  in  others  it  is 
cedematous,  not  unfrequently  receiving  the  impression  of  the  ribs. 
In  this  state  it  commonly  affects  most  the  lower  and  middle  lobes. 

A lung  in  this  state  shows,  when  examined,  that  its  tissue  is  ra- 
ther closer  than  usual,  and  contains  a large  quantity  of  blood  in  its 
vessels  and  filamento-cellular  tissue ; and  blood  is  beginning  to  be 
effused  into  the  air-cells.  This  is  the  state  called  obstruction  by 
Laennec.  It  is  the  close  of  the  state  of  congestion  or  injection. 

In  the  third  stage,  a new  series  of  phenomena  is  observed.  The 
blood,  which  had  been  previously  in  vessels  mostly,  and  was  fluid 
or  at  most  only  beginning  to  become  fixed,  is  now  observed  to  be 
extravasated  into  the  interstices  of  the  filamento-cellular  tissue. 
The  part  or  parts  of  the  lung  thus  affected  are  not  only  dark-red 
or  violet-coloured,  but  solid,  firm,  do  not  crepitate,  and  when  cut 
and  washed,  though  they  effuse  blood  and  bloody  serum,  the  section 
shows  patches  of  a rough  granular  aspect,  as  if  they  consisted  of 
small  granules  aggregated  together,  and  which  are  solid,  not  com- 
pressible, and  manifestly  totally  different  from  the  contiguous  por- 
tions of  lung.  At  first  these  patches  or  portions  with  soft  intervals 
are  small.  Afterwards  they  are  large ; and  in  some  instances  a 
large  portion  of  lung  at  once  passes  into  this  red,  solid,  rough, 
granular  condition. 

The  appearance  now  described  is  produced  by  blood  eflFused  into 
the  filamento-cellular  tissue ; and  the  eflFusion  thus  taking  place 
closes  and  obliterates  the  small  bronchial  tubes  and  air-cells.  Blood 
may  be  effused  into  these  parts  also,  and  commonly  is  effused. 

This  is  the  stage  of  red  solidification,  consolidation,  or  hepatiza- 
tion. Its  colour  is  various  shades  of  red,  according  to  the  state  of 
the  effusion  and  the  duration  of  the  disease.  In  some  instances  it 


984 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


is  brown,  and  in  some  violet  or  purple.  The  lung  so  affected  loses 
tenacity  and  becomes  friable. 

In  some  instances  this  change  is  of  a chronic  character,  and  it 
appears  to  occupy  weeks  or  even  months  in  its  progress  to  com- 
pletion. 

In  other  instances  it  seems  to  proceed  a certain  length  and  then 
to  stop,  leaving  considerable  portions  of  the  middle  and  lower  lobes 
in  a state  of  red  hepatization.  These  patches  are  easily  distin- 
guished by  being  dark- coloured,  while  the  adjoining  lung  is  more 
or  less  red ; by  being  solid  and  incompressible,  and  void  of  crepita- 
tion, while  the  other  parts  are  soft,  compressible,  and  crepitating, 
by  being  quite  insusceptible  of  inflation ; and  by  sinking  in  water. 
Sections  of  such  portions  of  lung  show  the  close  granular  appear- 
ance and  compact  structure  of  the  pulmonic  tissue  already  men- 
tioned. In  these  circumstances  the  pleura  is  in  general  healthy, 
and  it  is  not  uncommon  to  find  that  membrane  in  its  usual  state 
over  considerable  portions  of  lung  that  have  been  long  in  a state 
of  red  or  brown  solidification. 

As  a fourth  stage  of  pneumonia  has  been  generally  enumerated 
the  change  denominated  gray  hepatization.  It  appears  to  me  not 
certain  that  this  view  is  correct.  Gray  hepatization  appears  to  be  of- 
ten a change  not  succeeding  to  red  or  brown  consolidation,  but  one 
which  follows  a certain  stage  of  the  disease  in  a particular  form  and 
in  certain  constitutions.  Its  anatomical  characters  are  the  following. 

The  whole  lung  is  firm,  solid,  inelastic,  and  more  or  less  incom- 
pressible. It  fills  the  chest  completely,  and  usually  projects  a little 
when  the  sternum  is  removed.  The  pleura  is  very  generally  co- 
vered with  patches  of  lymph,  and  sometimes  it  adheres  extensively 
and  more  or  less  firmly.  The  lung  itself  is  most  solid  at  the  mid- 
dle and  lower  lobes,  and  the  upper  lobe  alone  is  soft  and  a little 
compressible.  Sections  of  the  lung  show  the  substance  to  be  of 
gray-red,  or  dirty  yellow  colour ; sometimes  with  portions  of  bluish- 
gray,  green,  orange,  and  in  short  variegated.  The  substance  is 
solid,  compact,  but  friable  and  very  easily  rent ; in  short,  it  comes 
away  under  the  fingers.  Much  serous  fluid,  more  or  less  turbid, 
with  some  blood-coloured  purulent  matter,  oozes  from  the  surface 
of  the  sections.  When  examined  by  the  microscope,  pus  globules 
are  seen  both  in  the  interstitial  matter  and  oozing  from  the  cut  sur- 
face. Granules  of  lymph  and  blood  are  also  observed  infiltrated  into 
the  interstices  of  the  filamento-cellular  tissue.  When  the  part  has 


MOEBID  STATES  OF  THE  LUNGS — PNEUMONIA. 


985 


been  macerated  or  well  washed,  the  section  presents  a granular 
compact  aspect  like  the  section  of  the  lung  in  red  consolidation. 
But  it  is  more  varied ; the  substance  of  the  lung  is  more  thoroughly 
destroyed  or  disguised,  and  the  lung  is  softer  and  more  lacerable. 
In  some  instances  the  portions  of  lung  present  a sort  of  tubercular 
induration,  that  is,  hardened  masses,  bluish-gray  or  gray  in  colour, 
and  of  irregular  form,  interspersed  among  whitish-gray  softened  por- 
tions. In  other  instances,  gray  portions,  firm,  yet  lacerable,  are 
interspersed  among  reddish  portions. 

It  is  impossible  to  doubt,  that  these  changes  depend  partly 
on  blood  infiltrated  and  changed,  and  in  a greater  degree  on 
lymph,  and  purulent  matter  infiltrated  into  the  filamento-cellular 
tissue.  Various  products  also,  as  blood,  liquor  sanguinis,  and 
lymph,  are  poured  into  the  air-cells  and  obliterate  them.  It  is  sup- 
posed by  some  that  this  causes  the  appearance  of  whitish  granules  in 
the  lung  affected  by  gray  hepatization.  It  may  do  so ; but  the  infil- 
tration of  this  matter  takes  place  also  into  the  filamento-cellular  tis- 
sue ; and  while  the  presence  of  one  set  of  granules  may  depend  on  the 
former  cause,  that  of  another,  it  appears  to  me,  depends  on  the  latter. 

In  short,  there  are  effused  blood- corpuscles ; liquor  sanguinis  or 
plasma,  afterwards  formed  into  granules ; and  pus-globules  all  at  the 
same  time  and  in  the  same  tissue.  The  blood-corpuscles  after  some 
time  undergo  changes  in  colour,  and  hence  arise  the  bluish-gray, 
greenish,  and  reddish  brown  or  orange  colours  of  the  parts 
affected. 

The  changes  now  specified  may  come  on  rather  gradually  and 
insidiously,  without  very  great  disorder  in  the  breathing,  until  the 
greater  part  of  one  or  both  lungs  is  destroyed  by  consolidation.  The 
disease,  if  it  do  not  begin  in,  certainly  affects  mostly  the  substance 
of  the  lung,  that  is  the  filamento-cellular  parenchyma;  and  along 
with  this  it  involves  the  pulmonic  air-cells,  which  are  filled  with 
blood  and  obliterated.  From  the  substance,  it  affects  eventually  the 
pleura  which  is  covered  with  lymph  recent  and  soft,  or  firm.  In  seve- 
ral instances  which  have  come  under  my  own  observation,  the  pa- 
tients did  not  complain  of  uneasiness  or  disorder  until  the  pleura 
began  to  be  inflamed.  In  general  death  was  then  not  remote,  and 
took  place  in  the  course  of  a few  days. 

Inflammation  usually  commences  in  the  lower  part  of  the  lung, 
and  generally  attains  there  its  greatest  intensity.  Thus,  the  whole 
of  the  lower  lobe  may  be  in  a state  of  extensive  induration  and  he- 


986 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


patization,  while  the  middle  lohe  is  only  reddened  and  infiltrated 
with  serum,  sero-sanguine  fluid,  or  blood,  and  the  upper  lohe  is 
comparatively  healthy.  The  centre  of  the  lung  also,  especially  op- 
posite to  the  lower  angle  of  the  scapula,  is  often  the  seat  of  inflam- 
mation. Inflammation  may  take  place  in  one  lung  or  in  both  ; and 
in  the  same  manner  it  begins  first,  and  attains  its  greatest  intensity 
in  the  lower  lobes  of  both.  In  the  former  case,  it  is  said  to  he  sim- 
ple ; in  the  latter,  it  is  double  pneumonia.  It  is  not  easy  to  esti- 
mate the  comparative  prevalence  of  pneumonia  in  either  lung,  or 
in  both ; but  from  the  attempts  made,  it  appears  that  pneumonia 
of  the  right  lung  is  more  common  than  in  the  left,  in  the  ratio  of 
more  than  two  to  one,  and  that  single  pneumonia  is  more  common 
than  double  pneumonia  in  the  ratio  of  six  to  one.* 

It  must  not  be  imagined,  however,  that  inflammation  is  always 
seated  in  the  lower  part  of  the  lung.  Morgagni,  Trank,  and  Brous- 
sais  often  found  the  upper  part  of  the  lung  inflamed.  In  the  sum- 
mer of  1837,  I found,  in  the  body  of  a woman  who  had  died  rather 
suddenly,  the  upper  part*of  both  lungs  in  a most  complete  state  of 
gray  hepatization ; and  in  several  cases  since  that  time,  I have 
found  the  upper  parts  of  the  lungs  affected  with  pneumonia  in  va- 
rious degrees,  while  the  lower  was  in  comparative  soundness.  The 
same  occurrence  is  admitted  by  Andral,  who  allows  that  it  is  not 
uncommon,  and  by  Chomel,  whose  experience  leads  him  to  regard 
it  as  frequent. 

Pneumonic  inflammation  may  terminate  in  resolution ; effusion  of 
blood  or  simple  hepatization ; effusion  of  blood  and  lymph  or  granular 
hepatization  ; and  suppuration  ; or  it  may  become  chronic,  and  ter- 
minate in  mixed  hepatization  ; or  it  may  terminate  in  gangrene. 

It  is  very  important  to  observe  with  regard  to  gray  hepatization, 
that  persons  labouring  under  it  die  apparently  very  unexpectedly, 
if  not  suddenly.  These  persons  have  perhaps  been  only  in  a sort 
of  general  ill-health,  when  all  of  a sudden  they  are  attacked  with 
great  difficulty  in  breathing  and  extreme  weakness,  and  in  this 
state  die,  or  even  without  this  preliminary  difficult  breathing,  they 
suddenly  fall  down  and  are  found  dead. 

Though  this  shows  that  the  disease  is  chronic  in  progress,  yet 

* Of  210  cases  of  pneumonia,  121  were  in  the  right  lung,  58  in  the  left,  25  double 
and  6 not  ascertained.  Among  75  cases  given  by  M.  Jules  Pelletan,  in  58  inflamma- 
tion was  in  one  lung,  in  17  in  both  at  once  ; in  the  right  the  disease  occurred  42  times  ; 
in  the  left  1 8 times  ; in  the  base  of  the  lung  24  times  ; in  the  apex  7 times  ; all  over 
24  times.  Memoire  Statistique  in  Memoires  de  I’Academie,  Tome  viiiieme  Paris,  1840. 


MOEBID  STATES  OF  THE  LUNGS. — PNEUMONIA.  987 


other  points  regarding  chronic  forms  of  the  disease  shall  be  im- 
mediately considered. 

Pneumonia  has  been  distinguished  by  practical  authors  and  no- 
sologists  into  several  varieties,  according  to  certain  modifying  cir- 
cumstances. The  following  list  comprehends  the  most  important, 
1.  Hemorrhagic  peripneumony  ; 2,  The  spurious  or  bastard  Peri- 
pneumony  {Peripneumony  Notha)  ; 3.  The  chronic,  slow,  or  latent 
{Pneumonia  Chronica') ; 4.  The  gastric  or  bilious  {Pneumonia  gas- 
trica  vel  Pneumonia  biliosa) ; 5.  The  nervous  or  Typhoid  Pneu- 
monia {Pneumonia  Nervosa  et  Typhodes) ; and  6.  The  malignant, 
pestilential,  or  gangrenous  {Pneumonia  septica  vel  Pneumonia  ma- 
ligna) gangraena  pulmonum. 

Haemorrhagic  peripneumony  ( Pneumonia  Haemorrhagica.) 
Cullen  observed,  that  pneumonia  had  a termination  peculiar  to 
itself,  namely,  the  effusion  of  a quantity  of  blood  into  the  cellular 
texture,  {i.  e.  the  filamentous  or  parenchymatous  tissue)  of  the 
lungs,  which  soon  interrupting  the  circulation  of  the  blood  through 
these  organs  produces  fatal  suffocation.  In  some  instances,  how- 
ever, this  extravasation  of  blood  does  not  produce  immediate  suffo- 
cation. These  appear  to  be  principally  when  the  effusion  takes 
place  in  limited  and  isolated  points,  for  instance,  forming  small 
amorphous  masses  about  the  size  of  a filbert  or  walnut  in  the  lower 
lobes  of  one  or  both  lungs.  The  portions  of  lung  thus  the  seat  of 
bloody  extravasation  become  firm,  resisting,  uncrepitating,  dark- 
coloured  and  granular  in  structure.  The  boundaries  are  generally 
distinctly  circumscribed,  and  the  difference  between  them  and  the 
surrounding  portion  of  lung  is  distinctly  marked.  When  near  the 
surface  of  the  lung  they  are  both  felt  and  seen  through  the  pleura 
by  the  deeper  brown  colour  over  them,  by  their  firmness  and  soli- 
dity, by  not  collapsing  while  the  rest  of  the  lung  collapses,  and  by 
breaking  down  instead  of  collapsing  when  they  are  compressed. 
In  these  dark-brown,  hard,  granular  masses,  the  blood-vessels  and 
the  bronchial  tubes  and  vesicles  are  completely  obliterated,  and 
their  canals  closed,  and  the  membrane  of  the  contiguous  bronchial 
tubes  is  dark  brown,  thick,  and  friable. 

The  change,  indicated  by  the  presence  of  these  masses  in  the 
lung,  which  had  originally  been  described  by  Baillie  under  the 
name  of  the  brown  tubercle  of  the  lungs,  was  afterwards  made  the 
subject  of  particular  attention  by  Laennec,  under  the  denomina- 
tion of  pulmonary  apoplexy.  The  chief  objection  to  the  term  is  that 


988 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


it  converts  into  a disease,  that  which  in  correct  pathology  is  the  effect 
of  morbid  action ; and  that  its  author  represents  this  lesion  as  the  pa- 
thological cause  of  haemoptysis.  Had  he  said  that  haemoptysis  or  he- 
morrhage from  the  lungs,  and  this  dark-brown  circumscribed  indu- 
ration of  the  lung  were  effects  of  the  same  cause,  the  representation 
would  have  been  more  just.  Both  these  phenomena  are  the  effects 
of  the  previous  congestion  and  injection  of  the  lungs  which  termi- 
nates in  this  extravasation;  and,  providing  the  extravasated  fluid  get 
into  the  bronchial  tubes,  it  may  be  coughed  up  in  the  form  of  blood 
more  or  less  pure.  In  general,  even  when  blood  is  coughed  up 
in  this  manner,  a quantity,  more  or  less  considerable,  is  at  the  same 
time  effused  into  the  interstices  of  the  pulmonic  filamentous  tissue, 
where  it  stagnates,  and  at  length  coagulating  gives  rise  to  the  gra- 
nular dark -coloured  solid  indurated  masses  found  on  dissection,  dis- 
seminated through  the  lung.  These  masses  are  not  the  cause,  but 
the  effect  of  the  hemorrhage,  which  is  itself  the  effect  of  previous 
congestion. 

The  change  now  mentioned  is  often  found  in  the  lungs  as  an 
effect  of  disease  of  the  heart,  especially  degeneration,  ossification, 
and  arctation  of  the  mitral  valve.  But  I have  observed  it  take 
place  independent  of  this ; and  I have  met  with  a remarkable  in- 
stance of  it  in  the  lungs  of  an  infant  of  twelve  or  thirteen  months. 

These  and  other  circumstances  lead  me  to  regard  this  change  as 
one  of  the  effects  of  pneumonic  inflammation,  and  I therefore  refer 
it  to  the  present  head  under  the  name  of  hemorrhagic  peripneu- 
mony,  {pneumonia  hcemo)  rhagica.') 

Of  the  other  varieties,  the  second  is  rather  a species  of  vesicular 
bronchitis,  and  as  such  has  been  already  described  under  its  proper 
head. 

The  third,  viz.  the  chronic  or  latent  peripneumony,  occurs  under 
two  forms,  chronic  inflammation  of  the  pulmonic  tissue,  and  inflam- 
mation of  the  lobules. 

§ 2.  Chronic  Pneumonia. — In  the  first  it  presents  the  same  anato- 
mical characters  as  the  acute  disease,  but  comes  on  in  a more  insi- 
dious and  gradual  manner.  Andral,  indeed,  represents  the  ana- 
tomical character  of  chronic  pneumonia  to  be  hardening  of  the 
pulmonic  tissue,  with  a yellow,  gray,  blue,  black,  or  brown  tint,  with 
impermeability  to  air.  This,  however,  is  the  ultimate  result  of  a 
series  of  changes,  in  which  the  portion  of  lung  has  been  previously 
the  seat  of  red  coloration  and  congestion,  infiltration  of  blood,  and 


MOEBID  STATES  OF  THE  LUNGS. — LOBULAE  PNEUMONIA.  989 


at  length  infiltration  of  blood  and  lymph.  In  this  mode  it  most 
frequently  steals  on  imperceptibly,  with  cough  aggravated  in  the 
winter  season  and  on  exposure  to  cold,  slight  dyspnoea  which  in- 
creases gradually,  very  slight  febrile  symptoms  aggravated  during 
the  night,  gradual  wasting  and  eventually  death,  either  by  bastard 
peripneumony,  a sudden  and  unexpected  attack  of  the  acute  dis- 
order, or  the  establishment  of  pleuritic  Inflammation. 

In  less  frequent  cases  the  same  change  is  sometimes  left  as  a 
residue  of  the  acute  form  of  the  disorder. 

§ 3.  Lobular  Pneumonia In  the  second  form  of  chronic  pneu- 

monia the  inflammatory  disorder  comes  on  in  a different  manner. 
Either  at  the  same  time,  or  successively  inflammatory  congestion, 
indicated  by  redness,  induration,  and  at  length  the  effusion  of  blood 
and  lymph,  takes  place  in  several,  sometimes  many  points,  of  one 
or  both  lungs.  This  goes  on  for  weeks  or  months,  until  the  whole 
of  both  lungs  present  a multitude  of  roundish  or  irregular  formed 
nodules  about  the  size  of  small  nuts,  difiused  through  their  sub- 
stance. When  these  are  divided  by  the  knife  they  present  an  ex- 
terior of  reddish,  firm  vascular  substance,  inclosing  in  general 
small  grains  of  grayish-coloured  matter,  sometimes  like  coagulated 
lymph,  sometimes  like  purulent  matter.  They  are  manifestly  con- 
fined to  the  minute  divisions  or  lobules  of  the  lungs,  and  as  the  in- 
flammatory action  has  thus  originated  in,  and  been  chiefly  confined 
to  these  lobules,  the  disorder  has  not  improperly  been  denominated 
lobular  ■pneumonia^  {pneumonia  lobulorum.')  The  lungs  at  the  same 
time  are  infiltrated  with  serum  ; the  bronchial  tubes  contain  puri- 
form  mucus ; the  pleura  is  invariably  more  or  less  inflamed  and 
covered  with  patches  of  albuminous  exudation,  especially  opposite 
to  those  inflamed  lobules  which  approach  nearest  to  the  pleura  pul- 
monalis ; the  pulmonic  and  costal  pleurae  are  often  united  by  soft 
recent  adhesions ; the  upper  part  of  the  apex  of  the  lung  generally 
adheres  extensively  ; and  sero-albuminous  or  puriform  fluid  is  found 
in  the  cavity  of  the  pleura. 

The  symptoms  of  this  disorder  are  imperfectly  known.  In  the 
few  cases  which  have  fallen  closely  under  my  observation,  the  exis- 
tence of  disease  of  the  lungs  was  not  even  suspected ; and  in  one 
case  which  I had  occasion  to  inspect,  the  patient,  a boy  of  fif- 
teen, was  supposed  to  have  died  of  continued  fever.  Febrile  symp- 
toms, indeed,  he  presented  for  about  eight  or  nine  days  previous 
to  the  fatal  event,  and  at  the  same  time  the  breathing  was  rapid. 


990 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


he  complained  of  headach,  and  afterwards  a little  delirium  and 
coma  ensued.  I learned  from  his  relatives  that  he  had  habitual 
difficult  breathing,  but  I could  not  ascertain  that  he  had  cough  or 
expectoration. 

Besides  the  morbid  state  of  the  lungs  in  this  form  of  disorder, 
it  is  usual  to  find  inflammatory  redness  and  enlargement  of  the 
muciparous  follicles  of  the  colon,  the  caecum,  and  sometimes  of  the 
ileum,  and  these  may  be  affected  with  ulceration. 

The  meninges  also  are  generally  injected,  and  fluid  is  formed  in 
the  subarachnoid  tissue,  within  the  ventricles,  and  within  the  spinal 
theca. 

This  form  of  pneumonic  inflammation  is  most  usually  found  in 
children  and  young  persons.  Its  causes  are  imperfectly  known. 
But,  from  the  circumstance  of  its  being  often  associated  with  the 
disorders  of  the  joints,  bones,  and  similar  tissues  usually  imputed 
to  the  influence  of  the  strumous  diathesis,  its  development  may  be 
inferred  to  be  dependent  on  the  presence  of  this  diathesis,  and 
created  by  exposure  to  cold  or  some  similar  exciting  causes.  From 
the  peculiar  form  which  it  assumes,  and  from  its  association  with 
ulceration  of  the  intestinal  follicles,  as  well  as  the  circumstances  in 
diathesis  already  mentioned,  I regard  it  as  the  early  stage  of  tuber- 
cular consumption.  The  only  reason  that  it  is  not  so  frequently 
met  with  as  the  other  ordinary  forms  of  pneumonia,  is,  that  it  sel- 
dom proves  fatal  in  the  early  stage,  or  before  it  has  not  only  occu- 
pied the  whole  of  both  lungs  with  the  morbid  deposit,  but  produced 
more  or  less  excavation. 

Marks  of  chronic  diffused  pneumonia  are  always  found,  in  every 
case  of  tubercular  infiltration  and  destruction  of  the  lung. 

The  gastric  or  bilious  pneumonia  has  been  rendered  a subject  of 
great  importance  by  Lepecq  de  la  Cloture,* * * §  Stoll,f  Romain,j;  Ac- 
kermann,§  Jansen, ||  Guidetti,1F  Borsieri,  Goeden,  Hauff,  and  vai'i- 
ous  other  foreign  physicians.  Its  existence  as  a form  of  peripneu- 
mony  is  almost  denied  by  Andral,  and  I confess  that  in  this 
country  it  is  seen  so  rarely,  as  to  justly  give  rise  to  doubts  of  its 

* Lepecq  de  la  Cloture  Observat.  s'lr  les  Maladies  Epidemiques.  Paris,  1776. 

T Ratio  Medendi,  Vol.  iii.  iv.  and  v.  Part  II.  v.  vii.  p.  112,  117,  346. 

+ Romain  Essai  sur  la  Maniere  de  Traites  les  Peripneumonies  Bilieuses.  Metz,  1779. 

§ Ackermann  Pleuritidis  Biliosse  brevis  adumbratio.  Kiliae,  178S. 

II  Dissert,  de  Peripneumonia  Biliosa.  Goett.  1787. 

*U  Guidetti,  Dissert,  de  Pleuritide  Biliosa.  Heidelberg,  1790. 


MORBID  STATES  OF  THE  LUNGS. — PNEUMONIA. 


991 


individual  and  independent  reality.  Pneumonia  doubtless  takes 
place  in  persons  in  whom  the  alimentary  functions  are  disordered, 
and  sometimes  the  hepatic  secretions  perverted  or  deranged ; and 
it  sometimes  happens  that  symptoms  of  gastric  and  hepatic  dis- 
order simulate  symptoms  of  pneumonic  inflammation.  The  first 
must  be  regarded  as  a mere  complication,  such  as  is  very  frequently 
met  with  in  practice.  The  second  must  be  viewed  as  a distemper 
totally  diflFerent,  and  requiring  different  treatment. 

The  class  of  persons  in  whom  pneumonia  and  bronchitis  is  ob- 
served to  assume  the  bilious  or  gastric  disorder  in  this  country 
most  frequently  are  the  intemperate,  especially  spirit  and  wine- 
hibbers,  the  gouty,  and  those  labouring  under  mental  anxiety  and 
distress. 

§ 4.  The  term  nervous  or  typhoid  'pneumonia  has  been  applied  to 
pneumonia  taking  place,  as  it  often  does,  along  with  typhoid  fever, 
or  giving  rise  to  symptoms  of  typhoid  fever.  Of  this  variety  two 
forms  may  be  specified. 

Is^,  Either  a person  attacked  with  continued  fever  presents  in 
the  course  of  it  symptoms  of  bronchial  inflammation  or  even  pneu- 
monia, not  very  well  marked,  but  still  sufficiently  so  to  be  recog- 
nized by  the  skilful  observer.  Sometimes,  not  always,  there  is 
cough ; for  in  certain  cases  the  patient  is  so  feeble  that  he  is  unable 
to  cough  or  expectorate.  In  general  the  respiration  is  laborious, 
limited,  and  irregular ; the  face,  cheeks,  and  lips  are  livid ; the 
hands  and  feet  livid  and  cold ; and  the  pulse  small,  soft,  and 
sometimes  irregular  or  intermitting.  Upon  employing  ausculta- 
tion the  presence  of  pneumonia  in  the  posterior  and  inferior  region 
of  one  or  both  lungs  is  recognized.  In  this  form  of  the  disorder 
it  is  said  to  be  typhoid  fever  with  pneumonia. 

^d.  In  a person  attacked  with  pneumonic  inflammation,  the 
symptomatic  fever  does  not  assume  the  open  and  distinct  symptoms 
usually  presented,  but  observes  a slow,  latent,  and  insidious  form, 
in  which  the  symptoms  of  great  feebleness  {adynamia)  and  nervous 
irritation  [neurasthenia)  are  predominant.  Of  these  the  most  pro- 
minent are  great  oppression  at  the  breast,  intolerable  anxiety,  and 
jactitation ; a sense  of  internal  heat ; great  difiiculty  in  breathing 
and  coughing ; total  cessation  of  pain  if  previously  felt ; a deceit- 
ful calm  or  listlessness ; delirium  in  the  night  especially,  or  typho- 
mania ; dryness  and  tremulousness  of  the  tongue,  unquenchable 
thirst,  meteorisraus  of  the  belly,  dry  burning  skin,  faintings,  sub- 


992 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


sultus  tendinum,  feebleness  of  the  voice  or  aphonia,  extreme 
debility  of  the  voluntary  motions,  great  softness  and  weakness  of 
the  pulse,  which  is  also  sometimes  quick,  sometimes  natural.  In 
some  cases  vomiting  or  hiecup,  or  both  ensue.  The  surface  of  the 
skin  presents  dark-coloured  petechial  spots  or  a miliary  eruption, 
especially  on  the  anterior  part  of  the  trunk.  Hemorrhages  from 
the  nostrils,  throat,  lungs,  stomach,  and  intestinal  tube  are  liable 
to  take  place;  the  urine' is  sometimes  dark-coloured  and  bloody; 
and  discharges  of  blood  from  the  uterus  in  females  are  not  unusual. 
The  blood,  if  drawn  from  a vein,  presents  in  general  a loose,  soft 
coagulum,  with  a small  proportion  of  serum.  In  a few  rare  cases 
the  clot  is  firm. 

As  the  symptoms  proceed,  the  delirium  or  typhomania  passes 
into  lethargic  sopor ; the  breathing  becomes  stertorous,  and  is 
attended  with  general  tracheo-bronchial  rattling ; the  pulse  be- 
comes small,  and  can  scarcely  be  felt ; convulsions  occasionally 
ensue ; the  head,  neck,  and  chest  are  covered  with  cold  fetid 
sweats ; the  extremities  become  cold,  and  death  follows. 

Morbid  anatomy  shows,  that  this  distemper  is  of  the  kind  deno- 
minated pleuropneumony,  with  vesicular  bronchitis.  Gluge  and 
Vogel  however  both  represent  the  substance  of  the  lungs  to  be 
consolidated  with  infiltration  of  dark-coloured  blood  in  patches. 
The  lungs  are  found  gorged  with  blood,  dark-coloured  and  dense 
towards  the  posterior  part,  not  indurated  or  consolidated,  but  rather 
oedematous  and  doughy.  The  surface  of  the  lung  presents  dark 
livid  patches.  The  pleurae  contain  sero-sanguine  or  sero-purulent 
fluid,  with  shreds  of  lymph.  Sometimes  even  the  pericardium  and 
the  peritoneum  present  fluids  of  the  same  kind,  with  flocks  of  lymph. 
The  chambers  of  the  heart  also  and  the  large  vessels  contain  large, 
loose,  soft  coagula  of  blood.  In  some  epidemics  the  intestinal  tube 
contains  lumbrici. 

A state  of  the  lungs  very  similar  to  this  is  observed  to  take  place 
in  persons  labouring  under  sea-scurvy.* 

§ 5.  Pneumonia  Septica.  Gangrjena  Pulmonum. — It  maybe 
doubted  whether  pneumonia  ever  legitimately  terminates  in  morti- 
fication or  gangrene  of  the  lung  ; and  there  is  some  reason  to 
think,  that,  when  mortification  does  take  place  in  these  organs,  it 

* Vide  Huxham,  chapter  ii.  p.  186,  and  Henderson,  Edinburgh  Medical  and  Sur- 
gical Journal,  vol.  iii.  p.  10. 


MORBID  STATE  OF  THE  LUNGS GANGRENE. 


993 


is  the  result  not  of  ordinary  inflammation,  but  of  a peculiar  kind 
of  inflammation,  the  tendency  of  which  is  to  gangrene. 

Gangrene  of  the  lungs  takes  place  either  as  a part  and  conco- 
mitant of  continued  fever  with  typhoid  symptoms  and  pestilential 
fevers  in  general,  or  it  may  occur,  so  far  as  it  is  possible  to  judge, 
as  a primary  species  of  inflammatory  disorder  of  the  lungs. 

a.  In  the  first  case,  a person  with  the  usual  symptoms  of  aggra- 
vated and  rather  intense  typhoid  fever,  and  commonly  with  marks 
of  imperfect  general  circulation  and  perverted  and  imperfect  pul- 
monary circulation,  as  lividity  of  the  face,  nose,  cheeks.  Ups,  and 
extremities,  coldness  of  the  extremities,  hiccup,  and  small  pulse, 
presents  obscure  symptoms  of  disorder  of  the  lungs,  laborious  and 
irregular  respiration,  sometimes  hurried,  sometimes  slower  than 
natural,  slight  cough,  at  first  dry,  afterwards  moist  with  sputa, 
very  viscid,  glutinous,  orange-coloured,  streaked  with  blood,  and 
very  fetid  offensive  breath.  The  sound  upon  percussion  is  more 
or  less  dull ; and  upon  auscultation,  either  the  crepitant  rattle, 
sometimes  with  large  bells,  is  heard,  or  this  is  heard  with  inaudi- 
bility of  the  vesicular  sound  most  usually  In  the  subscapular  and 
inferior  convex  region  of  one  or  both  lungs.  With  these  symp- 
toms are  usually  associated  great  feebleness,  delirium  or  typho- 
mania,  intermittent,  irregular  small  pulse,  a tendency  to  gangrene 
of  the  extremities  and  sacrum,  hiccup,  subsultus  teudinum,  diar- 
hoea ; and  at  length  with  increasing  difficulty  of  breathing,  fetor  of 
the  breath,  and  tracheo-bronchial  rattling,  death  ensues.  Some- 
times hemorrhage  takes  place  from  the  lungs,  and  contributes,  with 
the  other  marks  of  feebleness,  to  accelerate  the  approach  of  the 
fatal  event. 

|S.  In  the  second  case,  the  distemper  appears  to  come  on  at  first 
in  general  as  an  affection  of  the  lungs.  Either  the  patient  has  an 
attack  of  pneumonic  inflammation,  or  bronchial  disease,  or  spitting 
of  blood,  {hcBmoptysis),  with  more  or  less  dull  pain  in  some  part  of 
the  side  or  chest,  most  commonly  in  the  mammary  or  submammary 
region  before,  and  the  subscapular  region  behind,  and  sometimes 
as  if  passing  between  these  two  points.  Cough  continues  and  in- 
creases, with  sputa  in  general  reddish,  brown,  or  bloody,  and 
sometimes  with  pure  blood,  and  very  offensive  fetid  breath.  The 
countenance  is  anxious  and  livid ; the  complexion  dingy,  wan,  and 
leaden  coloured ; the  cheeks  occasionally  tinged  with  a reddish  or 
pink-coloured  flush  ; the  eye  heavy  and  pale,  sometimes  wild, 

3 B 


994 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


glaring,  and  slightly  suffused,  in  other  instances  hollow  and  ghastly. 
In  the  other  symptoms  considerable  variety  takes  place.  Thus  in 
one  case,  no  complaint  or  symptoms  appear  which  indicate  a serious 
disorder  of  the  lungs.  The  patient  is  merely  feeble,  with  dingy 
wan  complexion,  irregular  breathing,  cough,  and  a little  expecto- 
ration. In  other  cases,  pains,  more  or  less  acute,  are  felt  in  the 
chest,  and  the  labour  of  respiration,  with  debility,  is  considerable. 

The  most  characteristic  symptom  of  the  distemper,  the  foetid  of- 
fensive breath,  is  not  an  early  symptom.  It  does  not  take  place 
till  the  disease  has  subsisted  for  some  time,  two  weeks,  or  even  a 
longer  period ; and  indeed  it  appears  only  to  take  place  after  a 
communication  between  the  seat  of  disorder  and  the  bronchial  tubes 
and  the  air  inspired  and  exj)ired  has  been  established.  When  it 
takes  place  it  is  impossible  to  entertain  any  doubt  of  the  pi’esence 
of  the  distemper ; but  gangrene  of  the  lungs  may,  on  the  other 
hand,  exist,  and  have  proceeded  to  a considerable  extent,  yet  with- 
out giving  rise  to  foetor  of  the  breath  and  expectoration. 

As  the  disease  advances,  expectoration  becomes  more  abundant, 
with  sputa  reddish,  brown,  blood-coloured,  or  consisting  of  blood 
more  or  less  pure,  and  the  characteristic  fetid  odour.  Respiration 
becomes  very  irregular  and  laborious,  being  at  one  time  slow',  at 
another  (juick  and  panting.  In  general,  immediately  before  the 
fetid  odour  of  the  breath  and  sputa  is  manifest,  more  or  less  stupor 
and  much  anxiety  come  on,  with  small,  feeble,  irregular  pulse. 

In  general,  after  the  foetor  of  the  breath  and  sputa  is  established, 
the  distemper  tends  rapidly  to  the  fetal  termination.  In  one  case 
which  fell  under  my  own  observation,  the  distemper  continued  thirty 
days  before  the  foetid  odour  of  the  breath  was  evinced.  The  breath 
and  sputa  were  foetid  on  the  thirtieth  day  of  the  disorder,  and  death 
took  place  the  second  day  afterwards.  In  one  of  the  cases  by  M. 
Schrceder,  death  took  place  nine  days  after  the  first  occurrence  of 
foetor.  In  another  case  attended  by  myself,  the  offensive  foetor  of 
the  breath  and  sputa  was  recognized  on  the  23d  of  February,  and 
death  took  place  on  the  6th  of  March,  eleven  days  after.  This,  I 
believe,  may  be  regarded  as  nearly  as  may  be,  the  latest  period 
that  life  is  likely  to  be  prolonged,  after  the  occurrence  of  well- 
marked  foetor  of  the  breath  and  sputa. 

The  duration  of  this  disease  varies  from  four  w'eeks  to  two  months. 
It  is  rare  that  physicians  witness  its  commencement ; for  it  is  only 
when  the  patient  can  no  longer  move  about,  or  pursue  his  ordinary 


MORBID  STATES  OF  THE  LUNGS. — GANGRENE. 


995 


occupations,  that  he  applies  for  assistance  ; and  in  general  the  dis- 
ease has  been  proceeding  for  eight  days  or  two  weeks  when  he  is 
first  seen. 

The  appearances  found  after  death  are  of  two  kinds.  One  is 
indicative  of  what  is  named  diffusive  gangrene  of  the  lungs,  the 
other  is  circumscribed.  In  the  first  case,  a mass  of  lung,  about 
two  inches  and  a half  or  three  inches  wide,  hut  irregular  in  figure 
and  outline,  is  converted  into  a soft,  pulpy,  dark  ash-coloured  sub- 
stance, which,  when  it  is  handled  or  pressed  by  the  finger,  falls 
down  into  a loose  moist  mass — emitting  a foetid  offensive  odour, 
without  trace  of  the  usual  structure  of  the  lungs,  except  a few 
bronchial  tubes,  and  blood-vessels  and  filaments  and  shreds  of  fila- 
mentous tissue.  This  mass  is  in  general  bounded  by,  but  it  does 
not  terminate  abruptly  in,  healthy  lung.  It  is  soft,  dingy,  and  in- 
filtrated with  a dark,  ash-coloured,  dirty  serous  liquor.  Occasion- 
ally the  surrounding  portion  of  lung  is  hepatized  or  infiltrated  with 
blood,  or  blood-coloured  serum ; the  bronchial  tubes  always  con- 
tain much  blood-coloured  viscid  mucus;  and  sometimes  pleura 
is  reddened,  covered  with  lymph  or  adhesions,  and  contains  fluid  in 
its  cavity. 

The  part  of  the  lung  most  usually  thus  mortified  is  either  in  the 
lower  lobe,  the  upper  part  of  the  lower  and  lower  part  of  the  middle 
or  upper  lobe  on  the  left  side,  or  the  middle  lobe  alone  on  the  right 
side ; that  is,  the  central  part  of  the  lungs,  but  verging  toward  the 
lower  part. 

In  the  second  form,  or  that  which  is  circumscribed,  a portion  of 
the  lung  generally  towards  the  surface,  presents  a dark-coloured 
hard  patch,  varying  in  size  from  a shilling  to  a half-crown  piece  or 
more,  often  pretty  exactly  circular,  bounded  all  round  by  healthy 
lung,  and  not  unusually  a distinct  reddened  circle  of  vessels,  or 
vessels  with  lymph.  This  circular  hard  patch,  which  resembles 
closely  an  eschar  produced  by  caustic  potass,  or  any  of  the  caute- 
ries, may  either  adhere  or  he  detached.  In  the  latter  case,  it  gene- 
rally leaves  disclosed  a cup-like  cavity,  a little  larger  than  the  de- 
tached eschar,  not  loose  or  filamentous,  or  shreddy-like  as  in  diffuse 
gangrene,  but  firm,  granular,  with  the  blood-vessels  and  bronchial 
tubes  closed,  and  with  the  surrounding  lung  more  softened,  but 
generally  presenting  marks  of  pleurisy,  pneumonia^  and  bronchitis, 
all  united.  Sometimes  albuminous  exudation  over  the  pleura  and 
within  its  cavity  is  found  to  have  taken  place, — a circumstance 


996 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


wliicli  is  to  be  ascribed  to  secondary  pleurisy  caused  by  the  inflam- 
mation induced  to  detach  the  dead  eschar. 

Though  these  forms  of  gangrene  of  the  lung  are  sometimes  dis- 
tinct, they  occasionally  take  place  at  the  same  time  in  the  same 
lung.  Thus  in  the  case  of  one  of  the  patients  who  was  treated  by 
myself,  a man  of  fifty-six,  diffuse  gangrene  was  observed  towards 
the  internal  and  anterior  surface  of  the  left  lung,  and  circumscribed 
gangrene  in  the  form  of  a cup-like  cavity  at  the  outer  surface  of 
the  same  lung. 

Laennec  represents  this  disease  as  occasionally  terminating  fa- 
vourably. Of  this  I have  never  seen  an  instance,  either  in  my  own 
practice,  or  in  that  of  any  of  my  colleagues  at  the  Royal  Infirmary. 
It  is,  indeed,  a disease  almost  necessarily  fatal,  whether  from  the 
kinds  of  constitution  in  which  it  occurs,  or  its  deleterious  effects  on 
the  lungs  and  their  functions. 

The  causes  of  gangrene  of  the  lungs  are  little  known.  The  dis- 
ease occurs  either  along  with  typhoid  fever,  or  gives  rise  to  typhoid 
symptoms.  It  is  more  common  in  persons  beyond  the  ages  of  forty- 
five  or  fifty,  and  especially  in  those  who  have  lived  intemperately. 
It  also  occurs  in  persons  much  younger,  or  between  twenty  and 
thirty-six.  But  very  often  in  persons  at  this  age,  it  is  found  to  have 
taken  place  either  during  a mercurial  course,  or  shortly  after  its 
completion. 

Some  authorities  regard  it,  especially  when  circumscribed,  as  the 
effect  of  pulmonary  apoplexy. 

I have,  when  treating  of  the  transporting  power  of  the  veins,  ad- 
verted to  the  fact,  that  when  gangrene  affects  the  lungs,  suppura- 
tion, or  a purulent  deposit,  is  liable  to  take  place  in  the  brain. 
From  the  cases  in  which  this  has  been  observed,  not  many  indeed, 
I think  that  it  is  impossible  to  doubt,  that  however  it  may  be  ex- 
plained, under  certain  circumstances  purulent  deposit,  either  within 
the  veins  and  sinuses  of  the  brain,  or  within  the  substance  of  the 
brain,  takes  place  after  gangrene  of  the  lungs  has  been  established. 
Yet  the  necessity  of  the  gangrenous  affection  to  the  production  of 
the  effect  is  not  obvious.  On  the  other  hand,  mere  suppuration  of 
the  lung  may  be  adequate. 

Gangrene  is  liable  to  attack  certain  forms  of  tubercular  excava- 
tion  and  vomicae  of  the  lungs.  To  this  attention  shall  be  directed 
afterwards. 

In  certain  circumstances,  this  disease  appears  to  prevail  epide- 
mically, whether  it  be  the  effect  of  a typhoid  or  pestilential  fever 


MORBID  STATES  OF  THE  LUNGS. — ABSCESS. 


997 


which  gives  rise  to  it,  or  it  depeuds  on  the  prevalence  of  some  pe- 
culiar telluric  or  atmospheric  miasma.  In  the  year  1348,  a febrile 
disorder,  with  intense  pneumonic  symptoms,  often  terminating  fa- 
tally by  profuse  or  continued  hemorrhage  from  the  lungs,  appeared 
in  Italy,  and  spread  between  that  year  and  1350  over  many  parts 
of  Europe,  destroying  much  of  the  population  of  different  countries 
in  an  incredibly  short  space  of  time.  This  disorder,  which  w'as 
emphatically  denominated  by  the  populace  the  black  death,  appears 
to  have  possessed  the  character  of  fever  with  gangrenous  pneumo- 
nia. In  many  pestilential  epidemics,  however,  as  in  that  of  Mar- 
seilles, Transylvania,  and  other  countries,  carbuncular  and  glan- 
dular plague  appears  to  have  been  attended  with  symptoms  of  pul- 
monary mortification. 

Pneumonic  inflammation,  very  often  with  vesicular  bronchitis, 
occurs  secondarily  in  ague,  remittent  fever,  typhoid  fever,  small- 
pox, measles,  pulmonary  consumption,  rheumatism,  and  rheumatic 
gout,  and  disease  of  the  kidney.  I have  also  observed  the  disease 
take  place  in  a latent  or  insidious  manner  in  the  insane  from 
chronic  meningeal  inflammation. 

§ 6.  Vomica  or  Abscess  of  the  Lungs. — To  complete  the 
history  of  pneumonic  inflammation,  I add  a few  remarks  on  abscess 
of  the  lungs,  and  a form  of  suppurative  inflammation  to  which  they 
are  liable. 

The  formation  of  a distinct  abscess  of  the  lungs  as  a consequence 
of  inflammation,  was  at  one  time  generally  admitted  among  patho- 
logists. Laennec,  however,  wdio  describes  suppuration  of  the  lungs 
under  his  third  degree  of  pulmonary  induration,  maintains  that  it 
is  exceedingly  rare,  and  gives  it  as  the  result  of  his  observation, 
that  small  abscesses  are  found  in  the  pulmonic  tissue  not  above 
four  or  five  times,  and  an  extensive  one  not  above  once,  in  many 
hundred  cases.  Grray  hepatization  is  in  one  sense  suppuration  of 
the  lungs;  for  pus-globules  are  found  in  the  interstices  of  the 
filamento- cellular  tissue,  and  are  observed  oozing  from  it.  This 
however  is  infiltration  of  purulent  matter,  not  an  abscess  or  deposit 
in  a particular  cavity.  Many  of  the  reported  cases  of  pulmonarv 
abscess,  or  suppuration  of  lung,  as  a consequence  of  inflammation, 
may  be  regarded  as  excavations  or  vomiccB  formed  by  the  softening 
of  extensive  tubercular  masses.  Several  also,  I am  satisfied,  are  in- 
stances of  chronic  pleurisy  terminating  in  empyema  and  condensed 
lung.  It  is  possible  that  suppuration,  as  a consequence  of  inflam- 
mation of  the  lungs,  may  be  rare,  for  two  reasons;  “Because 


998 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  disease  may  prove  fatal  by  suffocation,  before  it  has  attained 
the  complete  suppurative  stage ; 2fZ,  Because  under  the  influence 
of  remedies,  it  may  be  so  much  modified  as  to  prevent  the  forma- 
tion of  purulent  matter  in  a distinct  sac  or  cavity.  But  it  must 
not  be  regarded  as  so  rare  as  M.  Laennec  represents  it.  Instances 
are  recorded  by  Moi’gagni,  in  which  a considerable  portion  of  the 
pulmonic  tissue  was  converted  into  a purulent  abscess,  with  the 
contiguous  structure  apparently  healthy,  or  indurated  as  a conse- 
quence of  previous  inflammation.  Dr  Baillie  expresses  himself 
with  some  uncertainty ; for  his  language  may  be  interpreted  so  as 
to  apply  either  to  tubercular  vomicae,  or  to  pulmonary  abscesses; 
though  it  is  evident,  and  more  especially  from  what  he  says  in  his 
engravings,  that  he  believed  in  its  ordinary  occurrence. 

On  this  subject  evidence  is  defective ; and  several  good  cases, 
with  the  appearances  after  death  are  required,  in  order  to  ascertain 
the  frequency  or  the  general  occurrence  of  abscess  as  a consequence 
of  pneumonic  inflammation. 

It  is  impossible  to  doubt,  nevertheless,  that  suppuration  of  the 
lungs,  that  is,  the  proper  pulmonic  filamentous  tissue,  does  take 
place  as  an  effect  of  inflammation  of  that  tissue.  In  this  instance, 
purulent  matter  of  a gray  dirty  aspect  is  formed  beneath  the  pleura 
or  the  subserous  cellular  tissue,  and  extends  in  this  direction  be- 
tween the  lobes.  An  excellent  example  of  this  lesion  occurred  to 
me  in  the  course  of  July  1843.  A man  in  an  extreme  state 
of  feebleness  presented  himself  for  admission  to  the  hospital.  It 
was  manifest  that  he  was  in  the  last  stage  of  some  serious  disease 
of  the  lungs ; and  death  took  place  in  the  course  of  a few  hours. 
Inspection  disclosed  the  following  state  of  the  lungs.  The  ’pleura 
of  both  lungs,  but  especially  of  the  right,  were  detached  from  the 
subjacent  substance  of  the  lung  by  a quantity  of  dirty  ash-coloured 
purulent  matter.  In  the  right  lung,  this  detachment  with  the  cor- 
responding purulent  matter  extended  into  the  division  of  the  lobes 
and  lobules,  which  were  thus  separated  from  each  other.  The 
filamento-cellular  tissue  appeared  as  if  it  had  been  dissolved  and 
carried  away  in  the  purulent  collection ; for  it  was  no  longer  cog- 
nizable in  its  wonted  characters.  When  the  matter  was  washed 
away,  bronchial  tubes  and  blood-vessels  were  all  that  was  left;  and 
these  did  not  adhere  as  they  are  wont  to  do.  In  short  the  cohesion 
of  the  whole  of  the  lower  and  middle  lobe  of  the  right  lung  was 
entirely  destroyed. 

Another  example  of  the  same  lesion  is  recorded  by  Dr  Stokes  in 

4 


MORBID  STATES  OF  THE  LUNGS. — DEPOSITS  IN  THE  VEINS.  999 


the  third  volume  of  the  Dublin  Medical  Joxu'ual.  This  gentleman 
found  in  the  body  of  a young  man  who  died  after  labouring  for 
fifteen  days  under  symptoms  of  pneumonic  inflammation,  a consi- 
derable collection  of  purulent  matter  beneath  the  pulmonic  pleura 
of  the  lower  lobe  of  the  left  lung,  and  between  it  and  the  bronchial 
tubes  and  vesicles  of  the  lung — dissecting  away  as  it  were  the 
pleura,  from  the  lung,  destroying,  or  at  least  converting  into  puru- 
lent matter,  the  pulmonic  filamentous  tissue,  and  leaving  the  pul- 
monic vesicles  and  bronchial  tubes  comparatively  untouched.  This 
must  be  regarded  as  not  only  an  example  of  suppuration  of  tbe 
lung,  but  as  proving  clearly,  that  the  seat  of  this  form  of  pneumo- 
nia is  in  the  pulmonic  parenchyma  or  filamentous  tissue,  as  already 
inculcated.* 

§ 7.  Pulmonary  Phlebitis.  Collections  of  Matter  in 
THE  Veins  of  the  Lungs. — I have  met  with  two  or  three  ex- 
amples, in  which,  without  expecting  any  morbid  appearance, 
I found  the  pleura  sound,  the  lungs  interspersed  at  considerable 
distances  with  numerous  minute  abscesses,  but  tbe  intermediate 
tissue  quite  healthy.  As  it  occurred  that  these  were  softened 
tubercles,  the  whole  organ  was  carefully  examined,  yet  without 
finding  anything  but  minute  spberical  abscesses  of  various  sizes, 
and  with  the  surrounding  texture  natural.  The  peculiarity, 
therefore,  of  this  species  of  suppuration,  is  its  not  being  preceded 
by  tubercles,  the  surrounding  pulmonic  tissue  being  neither  in- 
flamed nor  indurated,  and  the  simultaneous  formation  of  many 
purulent  points. 

Dr  Baillie,  by  whom  this  species  of  suppuration  had  been  seen, 
thought  it  probable  that  the  abscesses  were  produced  by  a number 
of  scattered  tubercles  taking  on  the  process  of  suppuration.  When 
however  these  purulent  collections  are  carefully  examined,  they  are 
found  to  take  place  within  the  veins  of  the  lungs.  Of  this  I am 
satisfied  from  having  observed  these  deposits  ensue  after  inflamma- 
tion of  the  veins  of  the  arm,  consequent  on  blood-letting.  They 
take  place  also  after  amputation  of  the  extremities,  in  which  the 
medullary  membrane  and  veins  of  the  bones  have  been  inflamed 
and  suppurate,  and  occasionally  after  other  injuries  which  proceed 
to  suppuration.! 

* Dublin  Journal  of  Medical  Sciences,  vol.iii.  Contributions  to  Thoracic  Patliologv, 
by  Dr  Stokes,  p.  51. 

t Observations  on  Depositions  of  Pus  and  Lymph  occurring  in  the  Lungs  and  otlier 
viscera  after  injuries  of  different  parts  of  the  Body.  By  Thomas  Rose,  Esq.  &c.  Me- 
dico-Chirurgical  Transactions,  Vol.  xiv.  p. '251.  London,  1828. 


1000 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


This  has  been  mentioned  by  Gluge  as  taking  place  after  glan- 
ders and  metastatic  inflammation  ; and  he  considers  the  purulent 
matter  as  deposited  in  the  pulmonic  filamento-cellular  tissue.*  It 
appears  to  me  that  though  this  may  take  place  occasionally,  yet 
these  collections  are  very  generally  in  the  veins  of  the  lungs. 

In  one  case  of  inflammation  of  the  uterine  veins,  with  matter  in 
them  and  the  common  iliac  veins  and  cava.  Dr  Lee  found,  with  he- 
patization of  the  lower  lobe  of  the  left  lung,  matter  in  the  pulmo- 
nary veins  and  lymph  in  the  pulmonary  trunk.f 

§ 8.  Deposits  of  Blood  in  the  Pulmonary  Arteries  after 
Phlebitis. — Another  effect  of  inflammation  of  the  veins  consists  in 
deposits  of  blood,  or  lymph,  or  both,  in  the  pulmonary  artery  and 
its  branches.  While  the  last  mentioned  deposit  of  purulent  matter 
succeeds  purulent  phlebitis,  this,  there  is  every  reason  to  believe, 
follows  lymphy  or  plasmatic  in  which  either  clots  of  blood 

or  lymph  are  formed  in  the  inflamed  vein.  The  following  is  the 
ordinary  mode  in  which  I have  seen  this  take  place. 

Symptoms  of  inflammation  appear  in  a vein  of  the  extremities  ; 
most  usually  in  the  common  femoral  or  external  iliac  vein,  which  is 
painful,  and  in  the  site  of  which  a hard  firm  swelling  is  felt,  with 
general  swelling  and  pain  of  the  veins  of  the  extremity.  This  pro- 
ceeds for  days  and  weeks,  until  the  interior  channel  of  the  vein  is 
more  or  less,  sometimes  completely  obstructed. 

Other  symptoms  indicative  of  more  or  less  disorder  in  the  organs 
of  respiration  take  place.  In  some  instances  purulent  eflPusion 
within  the  pleura  follows.  In  others  there  are  indications  of  de- 
rangement in  the  action  of  the  heart,  as  palpitation,  forcible  pulsa- 
tion in  the  cardiac  region,  irregular  or  intermittent  pulsation  and 
droj)sical  effusion.  At  length,  after  weeks  or  months,  death  en- 
sues, when  the  following  facts  are  observed. 

A bloody  or  lymphy  clot  more  or  less  firm,  sometimes  com- 
pletely solid,  in  the  external  iliac  and  common  femoral  artery  ; the 
coats  of  the  vein  thickened  and  not  collapsing,  and  their  inner 
membrane  rough  and  reddened  for  a considerable  space. 

In  some  cases  a clot  of  blood  or  lymph  adheres  most  firmly  to 
the  lacinice  of  the  tricuspid  valve,  or  to  the  walls  of  the  right  ven- 
tricle. When  the  pulmonary  artery  is  examined,  one  or  two  of  its 
branches  is  filled  more  or  less  completely  with  a brownish  firm  clot 

* Atlas  Der  Pathologischen  Anatomie.  Sechste  Lieferung.  Seite  5. 

•J-  Case  of  Pulmonary  Phlebitis.  By  Robert  Lee,  M.  D.  &c.  Medico-Cliirurgical 
Transactions,  Vol.  xix.  p.  -15.  London,  J 83S. 


MORBID  STATES  OF  THE  LUNGS. — HEMORRHAGE.  1001 


of  blood,  and  dispersed  through  the  lungs  are  similar  clots,  brown- 
ish-coloured, all  of  which  may  be  traced  to  divisions  of  the  pulmo- 
nary artery. 

This  disease  is  sometimes  chronic  in  its  course,  and  may  take 
ten  or  twelve  months  before  it  renders  the  lungs  unable  to  perform 
their  functions.  But  in  one  case  it  terminated  in  about  seven  or 
eight  weeks. 

The  occurrence  of  these  clots  of  blood  within  the  branches  of 
the  pulmonary  artery  has  been  noticed  by  Cruveilhier,*  M.  Baron,| 
Mr  James  Paget,|  and  Dr  Dubini.§  It  does  not  appear  that  in 
all  the  cases  recorded  by  these  observers,  there  was  proof  that  the 
circumstance  was  preceded  by  inflammation  in  any  veins  of  the 
extremities,  or  the  formation  of  clots  within  their  channels.  In 
several  of  the  cases,  the  obstruction  came  on  to  all  appearance 
spontaneously,  and  without  indications  of  previous  disease.  In  the 
case  given  by  Cruveilhier,  the  obstruction  was  connected  with  ute- 
rine phlebitis.  But  Mr  Paget  thinks  that  there  is  between  these 
cases  and  those  which  he  records  a great  difference.  The  cases 
mentioned  he  thinks,  connected  either  with  pulmonary  apoplexy, 
especially  if  dependent  on  disease  of  the  heart,  or  with  pneumonia, 
or  with  the  presence  of  enkephaloid  matter  in  the  blood,  or  with 
that  of  urea  in  the  blood,  as  in  the  case  of  granular  disease  of  the 
kidney,  in  which  he  finds  these  deposits  to  be  frequent.  It  appears, 
therefore,  that  the  formation  of  these  deposits  depends  on  several 
different  causes,  all  however  agreeing  in  some  morbid  state  of  the 
blood  or  the  veins. 

§ 9.  Pnetjmonoerhagia.  Hemorrhage  from  the  Lungs. — 
Discharge  of  blood  by  coughing  occurs  under  two  forms.  One  is 
that  of  bronchial  hemorrhage,  sometimes  copious,  but  often  in  small 
quantity.  The  other  is  that  of  pulmonary  hemorrhage,  which  may 
be  small  in  quantity,  but  is  generally  very  copious.  Of  the  former 
sufficient  notice  has  already  been  taken  under  the  head  of  diseases  of 
the  bronchial  membrane.  The  latter  is  to  be  considered  in  this  place. 

* Anatomie  Pathologique,  Livraison  xi. 

t Recherches  et  Observations  sur  la  Coagulation  du  Sang,  Dans  1-Artere  Pulmon- 
aire  et  ses  efFets.  By  M.  C.  Baron,  Archives  Generales  de  Medecine,  T.  xlvii.  p.  5. 
Paris,  1838. 

J On  Obstructions  of  the  Branches  of  the  Pulmonary  Arteries.  By  James  Paget, 
F.  R.  C.  S.  and  Medico-Chirm-gical  Transactions,  Vol.  xxvii.  p.  162.  London,  1844. 

Additional  Observations  on  Obstructions  of  the  Pulmonary  Arteries.  By  James 
Paget,  F.  R.  C.  S.  Medico-Chirurgical  Transactions,  Vol.  xxviii.  p.  352.  London, 
1845. 

§ Annali  Universal!  di  Medicina  di  Febraio,  1845. 


1002 


GENERi\X  PATHOLOGICAL  ANATOMY. 


On  the  exact  source  and  pathological  causes  of  spitting  of  blood, 
physicians  entertained  either  erroneous  or  indistinct  ideas.  The 
ancients  ascribed  it  to  rupture  of  some  of  the  pulmonary  vessels ; 
and  this  opinion  was  adopted  by  many  practitioners,  and  is  still  en- 
tertained by  the  vulgar,  to  whom  this  disease  has  been  long  known 
by  the  name  of  rupture  of  a hlood-vessel.  This  opinion,  however, 
is  manifestly  contradicted  by  anatomy  and  by  observation.  In  mo- 
dern times  this  opinion  regarding  the  pathology  of  pulmonary 
hemorrhage  is  found  to  be  correct  in  two  cases  only ; first,  when 
an  aneurismal  tumour  or  a diseased  artery  bursts  into  the  air  tubes 
{bronchia,')  or  the  windpipe ; and  secondly,  when  an  arterial  branch 
passing  through  a tubercular  excavation  has  given  way  during  the 
progress  of  ulceration.  Neither  of  these  cases,  it  is  obvious,  are 
necessarily  connected  with  true  pulmonary  hemorrhage.  Both  are 
followed  by  immediate  or  very  speedy  destruction.  But  the  process 
of  haemoptysis  may  recur  from  time  to  time  during  months  or  years 
in  the  same  individual,  or  even  the  whole  of  a long  life ; yet  with- 
out being  the  direct  cause  of  death. 

In  modern  times,  the  opinions  on  the  nature  of  pulmonary  he- 
morrhage may  be  referred  to  two  heads.  According  to  one  of 
these  views,  haemoptysis  is  the  result  of  an  actual  wound  or  breach 
in  the  bronchial  or  mucous  membrane  of  the  lungs.  This  was  the 
opinion  of  Barry,  Grant,  Gilchrist,  and  even  of  Cullen,  if  we  un- 
derstand him  ai’ight.  According  to  the  other  view,  which  is  more 
recent,  haemoptysis  is  believed  to  depend  on  some  disorder  of  the 
bronchial  membrane,  and  its  exhalant  vessels ; in  consequence  of 
which  they  discharge  blood  instead  of  mucus.  This  opinion  was 
that  of  Bichat,  who  has  been  followed  by  all  the  physicians  of  the 
Parisian  school,  and  by  many  in  this  country.  This  opinion  is,  as 
I have  already  shown,  well-founded  within  certain  limits  only. 
There  are  cases  of  haemoptysis  in  which  the  bronchial  membrane 
and  its  capillaries  only  or  principally  are  affected  ; and  then  the 
blood  which  is  occasionally  coughed  up  is  the  result  of  exhalation, 
or  of  destination,  as  it  used  to  be  named  by  the  older  pathologists. 
Such  are  the  discharges  of  blood  which  take  place  in  slight  cases 
of  haemoptysis  or  pulmonary  catarrh,  about  the  termination  of  pe- 
ripneumony,  about  the  commencement  of  consumption,  and  in 
young  females  after  the  suppression  or  retention  of  the  menstrual 
discharge. 

There  are,  however,  many  instances  of  bleeding  from  the  lungs 


MORBID  STATES  OF  THE  LUNGS HEMORRHAGE.  1003 


in  a violent  and  extreme  degree,  for  which  it  is  impossible  to  ac- 
count by  capillary  exhalation  only. 

Dr  William  Stark  was  the  first  who  described  accurately  the 
state  of  the  lungs  in  these  instances  of  hsemoptysis.  The  air  vesicles 
in  some  parts  of  the  lungs  he  found  filled  with  blood  or  bloody  se- 
rum. These  parts  did  not  collapse  on  opening  the  chest,  but  wei'e 
firm,  very  dark  or  light-red  in  colour,  and  could  neither  be  com- 
pressed nor  distended  by  the  usual  inflation.  When  cut  into,  thick 
blood  or  bloody  matter  issued  from  the  cut  surfaces ; and  portions 
of  the  diseased  parts,  after  being  for  some  time  macerated  in  water, 
still  sank  as  before  maceration.  He  further  showed  by  blowing  air 
into  the  blood-vessels  and  air- tubes  of  the  somid  and  diseased  por- 
tions respectively,  that  in  the  latter,  air  passed  from  the  branches 
of  the  pulmonary  artery  and  veins  into  the  bronchial  tubes, — in 
other  words,  that  the  minute  arteries  and  veins  or  capillary  vessels 
of  the  lungs  communicated  freely  with  the  bronchial  tubes  and  air- 
cells.* 

This  description  is  extremely  accurate,  but  appears  to  have  been 
altogether  overlooked.  Its  accuracy  has  been  confirmed  by  various 
subsequent  observers,  and  especially  by  the  researches  of  Laennec. 
The  facts  ascertained  in  this  manner  show  that  a considerable 
change  takes  place  in  hsemoptysis  in  the  pulmonary  substance,  or 
the  proper  tissue  of  the  lungs.  A portion  of  the  organ  becomes 
uniformly  hard,  of  a dark-red  colour,  and  impermeable  to  the  air. 
The  indurated  spot  is  always  partial,  fi-om  one  to  four  cubic  inches 
in  extent,  pretty  exactly  circumscribed,  with  healthy  or  pale-coloured 
lung,  and  looks  not  unlike  a clot  of  venous  blood ; circumstances 
by  which  it  is  to  be  distinguished  from  pneumonic  induration,  which 
terminates  more  or  less  gradually  in  sound  lung.  These  changes 
consist  in  efilision  of  blood  into  the  parenchyma  of  the  lungs,  and 
into  the  bronchial  tubes  ; and  as  they  are  analogous  to  those  which 
take  place  in  the  brain  in  apoplexy,  Laennec  applies  to  them  the 
name  of  pulmonary  apoplexy.  These  are  confined  chiefly,  however, 
to  the  severer  forms  of  pulmonary  hemorrhage. 

Not  even  is  this  description,  however,  suflacient  to  explain  all  the 
phenomena  of  pulmonary  hemorrhage.  The  changes  of  the  pul- 
monic tissue  described  by  Laennec,  are  rather  the  effects  of  a pre- 
vious morbid  state  of  the  capillary  circulation  of  the  lungs,  than  the 
actual  state  of  the  morbid  process,  which  gives  rise  to  eflFusion  of 
red  blood  from  the  bronchial  membrane.  When  the  lung  is  in  the 
* The  Works  of  the  late  William  Stark,  M,  D.,  &e,  London,  1788,  p.  34. 


1004 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


state  described  by  this  pathologist,  the  blood  has  been  already  dis~ 
charged  from  the  vessels,  or  extravasated  not  only  into  the  cells  of 
the  pulmonic  tissue,  but  into  the  minute  extremities  of  the  bronchial 
tubes,  which  are  thus  filled  and  obstructed  within,  while  they  are 
compressed  and  obliterated  without.  But  it  is  the  agent  that 
causes  this  effect,  which  it  is  the  object  of  the  pathologist  to  know  ; 
it  is  the  state  of  the  capillary  circulation  which  terminates  in  this 
effusion,  which  it  is  necessary  to  explain  in  unfolding  the  pathology 
of  pulmonary  hemorrhage.  This  it  w'ill  be  found  consists  in  more 
or  less  injection  and  distension  of  the  capillaries  or  minute  arteries 
and  veins  which  are  distributed  through  the  pulmonic  tissue,  to  w'ind 
round,  and  ramify  in  the  minute  or  extreme  bronchial  tubes,  in  con- 
sequence of  some  derangement  or  impediment  in  the  circulation. 

The  truth  is,  that  in  all  the  instances  of  the  lesion  described  as 
hemorrhage  into  the  substance  of  the  lungs,  whether  recent,  or  in 
the  form  of  pulmonary  dark-brown  induration,  it  is  preceded  either 
by  disease  of  the  heart,  or  disease  in  the  substance  of  the  lungs. 

1.  Bichat,  and  particularly  Cor  visart,  observed  that,  in  certain  forms 
of  disease  of  the  heart,  especially  the  active  aneurism  of  the  latter, 
or  what  is  at  present  termed  hypertrophy,  expectoration  of  blood 
was  a symptom  of  the  second  and  third  stages  of  the  disease.  Tlie 
same  circumstance  was  also  noticed  by  Mr  Allan  Burns,  who,  how- 
ever, has  hypothetically  connected  this  symptom  with  dilatation  of 
the  right  side  of  the  heart.  All  the  best  marked  cases  of  pulmonary 
hemorrhage  with  hemorrhagic  induration  which  I have  seen,  have 
been  connected  with  ossification  of  the  mitral  valve,  and  arctation 
of  its  aperture,  or  hypertrophy  of  the  left  ventricle.  The  operation 
of  the  former  it  is  easy  to  understand.  The  blood  does  not  pass 
with  its  wonted  facility  through  the  mitral  valve  into  the  left  ven- 
tricle ; the  left  auricle  is  consequently  kept  in  a constant  state  of 
over-distension ; this  distension  is  propagated  along  the  pulmonary 
veins  to  the  pulmonary  capillaries,  which  are  thus  perfectly  filled 
and  distended  with  blood,  which  is  not  allowed  to  be  moved  into 
their  trunks  in  the  usual  manner,  and  with  the  wonted  regularity. 
As  this  distension  is  every  hour  and  day  increasing,  with  the  per- 
sistence and  increase  of  the  obstruction  in  the  left  auriculo-ventri- 
cular  aperture,  it  is  not  wonderful  that  the  blood  is  extravasated 
into  the  pulmonic  filamentous  tissue,  and  through  the  bronchial 
membrane,  causing  in  the  former  the  dark  brown-coloured  circum- 
scribed masses  which  are  found  after  death,  and  in  the  latter  the 
bloody  expectoration  which  takes  place  during  life. 


MORBID  STATES  OF  THE  LUNGS. — HEMORRHAGE.  1005 


It  is  remarkable,  nevertheless,  that  this  extravasation  and  its 
effects  are  greatest  and  most  conspicuous  in  young  persons.  A 
degree  of  degeneration  of  the  mitral  valve  and  arctation  of  its  aper- 
ture, which  produces  little  inconvenience  at  or  beyond  the  age  of 
sixty  years,  causes  between  the  ages  of  twenty  and  thirty  extreme 
dyspnoea  and  ortliopncea,  cough,  heemoptysis,  and  all  the  accom- 
panying symptoms,  with  serous  infiltration  into  the  different  cavi- 
ties and  the  subcutaneous  cellular  tissue. 

Much  the  same  phenomena  may  take  place  in  consequence  of 
dilatation  or  hypertrophy,  general  or  partial,  of  the  left  ventricle. 
Olten,  indeed,  the  dilatation  or  excentric  hypertrophy  and  the  con- 
centric hypertrophy  are  the  result  of  disease  of  the  semilunar  valves 
at  the  origin  of  the  aorta ; but,  in  several  instances,  they  take  place 
independently  of  this.  When  they  do  ensue,  they  give  rise  to  a 
similar  state  of  imperfect  transmission  of  the  blood  out  of  the  ven- 
tricle into  tlie  aorta ; the  left  ventricle,  auricle,  and  pulmonary 
veins  become  unduly  distended ; and  eventually  the  pulmonary 
capillaries  are  constantly  distended  with  an  unusual  load  of  blood, 
which  at  length  is  extravasated,  and  causes  the  same  state  of  the 
lung,  and  the  same  expectoration  of  blood,  which  takes  place  at  an 
earlier  period  in  the  degeneration  of  the  mitral  valve. 

In  either  of  these  cases  now  specified,  but  especially  in  disease  of 
the  mitral  valve  and  arctation  of  the  auriculo- ventricular  aperture, 
in  hypertrophy,  and  in  that  rare  disease  called  partial  aneurism  of 
the  heart,  hemorrhage  of  the  lungs  may  take  place  in  one  or  other 
of  the  following  modes. 

After  a fit  of  great  difficulty  of  breathing,  generally  with  orthop- 
noea,  a quantity  of  blood  varying  from  one  to  six  ounces  is  brought 
up  forcibly  by  coughing.  In  one  instance  I saw  nearly  two  pounds 
coughed  up  in  the  course  of  about  thirty  hours.  In  such  cases  the 
large  fluid  rattling  and  gurgling,  is  heard  all  over  the  chest,  gene- 
rally on  both  sides.  From  this  state  recovery  is  sometimes  but 
rarely  effected.  Death  usually  takes  place  in  the  course  of  a few 
days,  not  so  much  from  loss  of  blood,  which  rather  relieves  the 
patient  than  otherwise,  as  from  the  extreme  difficulty  in  breathing. 
The  state  of  the  lungs  is  then  the  following.  They  are  completely 
gorged  with  blood ; of  a dark -red  or  very  livid  colour ; and  in 
several  points  brown  masses  not  firm  are  formed,  which  are  blood 
effused  into  the  filamento-cellular  tissue.  When  the  case  is  recent, 
these  masses  are  few  and  small,  sometimes  on  the  margins  of  the 


1006 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


lungs,  sometimes  deep  in  their  substance.  They  are  also  soft,  and 
the  blood  is  imperfectly  coagulated.  A curious  appearance  in 
lungs  of  this  kind  is  that  of  red-spotting  or  maculation  all  over  the 
surface  and  into  their  substance.  When  the  pleura  is  removed  by 
dissection,  these  spots  are  observed  to  lie  beneath  it  on  the  sub- 
stance of  the  lungs,  and  are  found  to  depend  on  blood  poured  into 
the  bronchial  tubes  and  extending  to  their  ultimate  terminations. 

Sprinkling  or  maculation  with  blood  in  the  lungs  from  its  pre- 
sence in  the  bronchial  tubes  and  air-vesicles,  I have  in  like  man- 
ner observed  in  the  lungs  of  persons  who  had  committed  suicide  by 
cutting  the  throat,  and  in  sheep  slaughtered  in  the  same  manner. 

The  lungs  in  this  state  are  heavy,  compact,  and  partially  con- 
densed: and  though  they  crepitate  and  contain  air  in  certain 
points,  yet  they  generally  sink  in  water. 

In  another  set  of  cases,  the  patient  is  attacked  with  a fit  of  ex- 
treme breathlessness,  amounting  to  orthopncea,  in  which  the  lips, 
nose,  and  cheeks  are  blue  or  violet-coloured,  and  by  coughing 
he  brings  up  at  length  frothy  mucus,  at  first  streaked,  then  mixed 
with  blood.  This  may  continue  for  two,  three,  or  eight  days,  when 
the  urgent  symptoms  subside,  and  the  bloody  expectoration  disap- 
pears. This  is  repeated  several  times  at  intervals  more  or  less  re- 
mote. The  fits  however  are  less  violent,  though  longer  continued. 
At  length  the  individual  has  fewer  and  less  distinct  intervals  of 
relief.  Breathlessness  is  either  constant,  or  very  nearly  so.  Cough 
continues,  with  expectoration  of  bloody  mucus,  and  blood,  some- 
times in  considerable  quantity.  When  death  ensues,  the  follow- 
ing is  the  state  of  the  lungs. 

Masses  of  variable  size,  but  sometimes  very  considerable,  that 
is,  as  large  as  a walnut  or  small  pippin,  dark-brown,  firm  and 
solid,  are  found  dispersed  through  the  lungs.  These  masses  are 
solid,  granular,  and  friable,  and,  though  firm,  may  be  broken  between 
the  fingers.  These  also  sink  in  water.  When  examined  carefully, 
it  is  easy  to  see  that  they  are  blood  extravasated  into  the  filamento- 
cellular  tissue  of  the  lungs.  The  vessels  are  closed ; the  bronchial 
tubes  obliterated,  at  least  not  permeable  to  air.  Little  of  the  lungs, 
indeed,  is  left  in  their  elastic  compressible  crepitating  condition. 

The  heart  is  found  either  in  a state  of  great  hypertrophy,  or 
w’ith  the  mitral  valve  ossified,  and  its  aperture  greatly  contracted. 
In  some  instances,  though  less  numerous,  the  same  state  is  found 
when  the  aortic  valves  are  ossified,  and  the  aortic  aperture  is  closed. 


MORBID  STATES  OF  THE  LUNGS. 


1007 


The  same  state  of  lungs  takes  place  in  partial  aneurism  of  the 
heart.* 

These  facts  may  be  regarded  as  established.  But  another  ques- 
tion remains  for  solution.  What  is  the  cause  of  this  distension  or 
injection  of  vessels,  when  it  cannot  be  traced  to  disease  of  the 
heart  ? What  is  the  nature  of  that  condition  of  the  pulmonary 
capillaries  which  allows  them  to  be  so  unusually  distended  ? What 
change  in  properties  do  they  undergo  in  living  persons  in  that  par- 
ticular portion  of  lung,  in  consequence  of  which  they  become  dis- 
tended with  blood,  which  stagnates  in  them,  and  at  length  is  forced 
from  them  by  extravasation  ? And  lastly,  why  does  this  state  not 
give  rise  to  inflammation  and  its  consequences  ? To  these  ques- 
tions no  satisfactory  answer  has  hitherto  been  given, 

2.  Profuse  hemorrhage  from  the  lungs  takes  place  in  consequence 
of  tubercular  deposition  and  infiltration.  In  various  persons  the 
deposition  of  tubercular  matter,  either  in  the  lungs  or  at  the  extre- 
mity of  the  bronchial  tubes  and  vessels,  induces  the  same  disorder 
in  the  motion  of  the  blood  through  the  pulmonary  capillaries  which 
takes  place  in  diseases  of  the  heart.  As  the  presence  of  these  bo- 
dies encroaches  both  upon  the  lungs  and  the  blood-vessels,  the  dif- 
ferent vessels  of  the  lung  become  distended  with  blood,  which  is 
not  allowed  to  move  through  them  with  the  natural  facility  and  ra- 
pidity ; accumulation  consequently  ensues ; and  afterwards  extra- 
vasation, and  sometimes  even  vessels  have  been  found  ruptured. 

When  the  tubercular  deposition  is  extensive,  and  beginning  to 
cause  vascular  congestion,  serous  extravasation,  and  softening,  it  also 
happens  not  unfrequently  that  the  vessels  become  much  enlarged 
and  distended ; their  tunics  at  the  same  time  are  involved  in  the 
morbid  changes,  become  thickened  and  covered  with  morbid  pro- 
ducts, and  are  thereby  rendered  bi’ittle  and  lacerable ; and  in  this 
condition  they  often  give  way  and  cause  profuse  hemorrhage. 

3.  Lastly,  it  has  been  observed,  in  inspecting  the  lungs  of  persons 
who  have  died  during  the  breaking  down  of  tubercular  masses,  and 
after  these  masses  have  been  excavated,  that,  though  in  general  some 
provision  is  made  against  the  ulcerative  destruction  of  the  blood- 
vessels by  coagula  being  formed  in  them,  and  by  their  cavities  being 
obliterated,  yet  in  some  instances  a vessel  has  been  found  passing 
near  or  across  a tubercular  cavity,  and,  having  been  opened,  has 

* Observations  and  Cases  illustrating  the  Nature  of  False  consecutive  Aneurism  of 
the  Heart.  By  David  Craigie,  M.  D.  &c.  Edinburgh  Medical  and  Surgical  Journal, 
Vol.  lix.  p.  356.  Edinburgh,  1843. 


1008 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


poured  forth  much  blood,  which  has  been  partly  brought  up  by- 
coughing,  and  partly  filled  the  cavity  with  bloody  clots,  as  was  ascer- 
tained by  inspection  after  death. 

The  causes  of  haemoptysis  may  be  understood  from  the  account 
already  given  of  the  different  circumstances  under  which  hemor- 
rhage may  take  place.  They  may  be  shortly  enumerated  in  the 
following  manner : First,  inflammatory  action  and  induration ; 
secondly,  hemorrhagic  induration,  with  or  without  disease  of  the 
heart ; thirdly,  disease  of  the  arteries  ; fourthly,  tubercular  depo- 
sition ; fifthly,  tubercular  destruction  and  excavation ; and  sixth, 
bronchial  hemorrhage. 

§ 10.  Tuberculatio.  Tyromatosis.  Tuberculosis.  State 
OF  THE  Lungs  in  pulmonary  Consumption. — In  the  bodies  of 
those  who  have  died  after  suffering  from  the  usual  symptoms  of 
pulmonary  consumption,  as  already  specified,  the  lungs  are  always 
more  or  less  changed  in  structure  and  more  or  less  destroyed.  In 
those  who  have  been  long  ill,  and  who  have  been  much  wasted,  the 
upper  regions  of  one  or  both  lungs  are  much  indurated,  and  occu- 
pied by  one  or  more  irregular-shaped  cavities  or  caverns,  contain- 
ing either  air,  or  air  and  a little  viscid  puriform  dirty-looking 
matter  adhering  to  their  walls. 

Very  generally  the  apex  of  one  or  both  lungs  is  firmly  attached 
to  the  inner  part  of  the  chest,  by  the  pulmonary  -pleura  adhering 
closely  to  the  costal  pleura  by  means  of  false  membrane,  which  is 
usually  thick,  firm,  and  cartilaginous.  The  extent  of  this  adhesion 
may  be  such,  as,  while  it  surrounds  the  whole  lung,  not  to  descend 
below  the  third  or  the  fourth  rib ; beneath  which  the  pleura  may 
be  free  from  inflammatory  exudation  or  adhesion ; it  then  forms  a 
sort  of  cartilaginous  cap  or  covering  of  the  apex  of  the  lung.  But 
in  some  instances,  while  the  pleura  investing  the  upper  lobe  ad- 
heres firmly  to  the  costal  pleura,  that  covering  the  lower  lobes  and 
the  middle  lobe  on  the  right  side  is  covered  by  a layer  more  or 
less  thick  of  albuminous  exudation,  while  a quantity  of  sero-puru- 
lent  fluid  is  found  in  the  posterior  part  of  the  thoracic  cavity. 
Almost  invariably  the  lobes  adhere  by  interlobular  false  mem- 
brane. 

Sometimes  the  greater  part  of  one  upper  lobe  is  hollowed  into 
one  large  irregular  cavity ; more  frequently  the  upper  lobe  pre- 
sents two  or  three  caverns,  either  isolated  or  communicating ; and 
in  some  instances  the  upper  lobe  is  occupied  by  a number  of  cavi- 


MORBID  STATES  OF  THE  LUNGS. — TUBERCLES.  1009 


ties  of  moderate  size,  some  containing  air,  others  pnriforra  dirty -look- 
ing mucus.  The  largest  cavities  are  most  commonly  formed  in  the 
apex  or  upper  region  of  the  upper  lobe ; but  occasionally  a con- 
siderable cavity  is  found  near  the  middle,  or  tending  towards  the 
base  of  the  upper  lobe,  and  corresponding  with  the  pectoral  and 
axillary  regions  externally.  Cavities  filled  entirely  or  partially  with 
matter  have  been  named  VomiccB,  sometimes  abscesses  rather  im- 
properly, and  with  greater  propriety  softened  tubercular  masses. 
When  wholly  or  partially  emptied,  they  are  usually  named  tuber- 
cular cavities,  or  cavities,  tubercular  excavations,  or  simply  excava- 
tions. 

Lower  down,  for  instance  in  the  lower  part  of  the  upper  lobes, 
the  cavities  are  few,  small,  or  none  ; in  the  middle  lobe  of  the  right 
side,  also  cavities  are  rarely  observed ; and  the  lower  lobes  of  both 
sides  are  in  general  entirely  free  from  cavities.  The  whole  of  these 
parts,  however,  are  more  or  less  indurated  by  the  presence  of  hard, 
solid,  irregular-shaped  masses,  variable  in  size,  but  in  general 
larger  and  more  numerous  in  the  upper  and  middle  region  of  the 
united  lungs  than  in  the  lower  region. 

When  the  caverns  (vomiccz,')  above  noticed,  are  examined,  they 
are  observed  to  vary,  not  only  in  size,  but  in  shape.  They  vary 
from  the  size  of  a large  pea  or  small  bean  to  that  of  a walnut,  a 
pigeon’s  egg,  or  even  a small  pippin.  Though  their  shape  is  more 
or  less  ovoidal,  they  are  always  irregular,  and  sometimes  consist  of 
one  large  or  considerable  cavern  with  two  or  three  small  append- 
ages. The  interior  is  always  irregular,  and  more  or  less  traversed 
by  cylindrical  bands  or  chords,  (septa,)  (trabeculce,)  about  the 
twelfth,  the  tenth,  or  the  eighth  of  an  inch  in  diameter,  passing  in 
various  directions,  but  generally  observing  that  of  the  longitudinal 
diameter  of  the  lung,  or  observing  a slight  degree  of  obliquity. 

These  bands  or  chords  (trabeculae,)  are  formed  in  various  modes. 
Laennec  believed  them  to  be  formed  of  the  natural  tissue  of  the 
lungs,  condensed  as  it  were,  and  charged  with  tubercular  matter, 
and  maintains  that  he  in  no  case  found  them  to  present  traces  of 
having  contained  blood-vessels.  Schroeder,  on  the  other  hand,  who 
frequently  injected  tuberculated  and  excavated  lungs,  represents 
them  to  be  formed  chiefly  by  the  gradual  and  progressive  oblitera- 
tion of  small  blood-vessels  by  means  of  inflammation,  the  large  ones 
receiving  nutriment  after  the  small  ones  have  ceased  to  do  so.=^ 

* Observationes  Anatomico-Pathologici  et  Practici  Argumenti,  Auctore  J.  C.  L. 
Schroeder  Van  der  Kolk,  Med.  et  Art.  Obstet.  Doct.  Fasciculus  I.  Amstelodami, 
1826,  8vo,  p.  77  and  78. 

3 s 


1010 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


It  is  not  improbable  that  they  consist  partly  of  inflamed  and  con- 
densed cellular,  that  is,  filamentous  tissue,  especially  that  investing 
the  lobules,  and  partly  of  obliterated  blood-vessels. 

The  inner  surface  of  a cavity,  chiefly  or  altogether  emptied, 
though  irregular,  rugged,  and  hollowed  into  several  subordinate 
depressions  and  eminences,  presents,  nevertheless,  a smooth  firm 
surface,  which  is  observed  to  be  owing  to  the  presence  of  a newly 
formed  membrane.  When,  indeed,  the  fluid  and  granular  matter 
is  removed  by  washing  it  repeatedly  in  water,  it  appears,  though 
hard  and  somewhat  cartilaginous,  to  be  almost  like  an  imperfect 
mucous  membrane,  or  rather  the  villous  surface  of  a fistula  or 
sinus.  This  Laennec  regards  as  a false  membrane,  or  newly  formed 
product ; and  certainly  it  presents  several  of  the  characters  of  false 
or  morbid  mucous  membrane.  Thus  it  is  thin,  smooth,  whitish,  or 
gray,  semitransparent,  soft,  friable,  and  easily  removable  by  the 
scalpel.  In  some  instances  subjacent  to  this  thin  semitransparent 
membrane,  are  one,  or  portions  of  one  a little  firmer,  rather  more 
opaque,  and  more  closely  adherent  to  the  walls  of  the  cavity. 

When  the  texture  surrounding  the  cavity,  and  forming  its  walls, 
is  examined,  it  is  found  to  he  solid,  firm,  incompressible,  almost 
cartilaginous,  entirely  void  of  elasticity,  more  or  less  dark-red  or 
brown,  and  serous  fluid  oozing  abundantly  from  the  divided  sur- 
faces. The  bronchial  tubes  passing  through  such  parts,  and  open- 
ing into  the  cavity  or  cavities,  are  often  enlarged,  and  their  mem- 
brane is  invariably  of  a deep  or  bright-red  colour,  rough  and  villous, 
and  lined  with  viscid  mucus.  In  general  these  bronchial  tubes 
are  cut  transversely  across,  or  truncated  at  the  point  of  junction 
with  the  cavity.  In  some  rare  cases,  one  bronchial  tube  is  found 
passing  through  a cavity  or  a vomica,  showing  that  it  has  escaped,  or 
resisted  the  destroying  process  which  commonly  cuts  it  through. 
This  fact,  noticed  by  Schroeder,  I have  also  seen.  But  in  general 
such  bronchial  tubes  are  at  length  destroyed,  if  the  life  of  the 
patient  be  sufficiently  prolonged.  Neither  Laennec  nor  Louis  ap- 
pear to  have  met  with  bronchial  tubes  within  cavities ; and  perhaps 
the  occurrence  is  rare. 

The  solidity  and  firmness  of  the  surrounding  texture  is  caused 
by  two  circumstances ; the  first,  the  presence  of  tubercular  deposi- 
tion in  the  lungs ; and  the  second,  inflammatory  induration. 

The  tubercular  deposit  appears  in  the  form  of  hard  masses, 
wliich  are  amorphous  or  void  of  regular  shape,  and  variable  in  size. 
IVhen  divided,  these  masses  are  solid,  firm,  sometimes  almost  car- 


MORBID  STATES  OF  THE  LUNGS TUBERCLES.  1011 


tilaginous,  of  a bluish  or  dirty  gray  colour,  and  when  closely  in- 
spected, consist  of  granular  bodies,  various  in  size,  from  a millet- 
seed  to  a small  pea,  closely  aggregated  together,  and  mutually 
pressing  each  other.  In  various  points  are  observed  portions  of 
whitish  or  grayish  coloured  viscid  semifluid  matter,  which  when 
removed  are  observed  to  be  contained  in  small  cavities.  Such 
masses  cannot  be  said  to  be  homogeneous.  Though  invariably 
much  more  Arm  and  incompressible  than  the  surrounding  lung, 
and  than  healthy  lung,  they  consist  of  portions  of  different  degrees 
of  consistence,  and  of  different  colour.  To  the  masses  and  their 
component  parts,  the  name  of  tubercles  is  indiscriminately  applied. 
It  would  be  more  correct  if  the  denomination  of  tubercle  were  con- 
fined to  one  or  the  other,  especially  to  the  smaller  component  por- 
tions ; in  which  case  the  large  masses  might  be  denominated 
tubercular. 

The  tubercular  masses,  as  thus  described,  may  occupy  the  supe- 
rior and  middle  parts  of  the  lungs,  leaving  very  little  of  the  sound 
lung  intermediate'  between  them.  Lower  down,  and  especially  in 
the  lower  lobe,  they  are  less  extensively  diffused,  and  smaller  in 
size,  so  that  portions  of  the  lung  are  unoccupied  by  them.  In 
general,  also,  they  are  more  abundant  at  the  posterior  than  at  the 
anterior  part  of  the  lungs. 

Tubercular  masses  vary  in  size,  and  may  be  distinguished  in 
this  respect  into  small,  middle-sized,  and  large.  The  small  masses 
are  those  about  the  size  of  garden  peas,  or  small  beans ; the 
middle-sized  are  those  about  the  size  of  a filbert,  or  small  goose- 
berry, and  all  those  above  this  may  be  designated  as  large.  In 
general,  when  they  have  attained  the  latter  dimensions,  they  have 
either  become  partially  softened,  or  they  have  begun  to  soften. 

Though  the  tubercular  masses  vary  in  size,  their  component 
parts,  viz.  the  minute  tubercles,  are  generally  about  the  same 
magnitude.  These  are  commonly  about  the  size  of  a millet-seed 
or  a little  larger ; but  in  general  the  whole  of  the  interior  of  a 
tubercular  mass  presents  in  the  advanced  stage  such  a confused 
mass  of  morbid  texture,  that  it  is  impossible  then  to  recognize  the 
individual  tubercles,  or  distinguish  them  from  each  other  and  the 
whole  mass.  It  is  only  by  examining  tuberculated  lungs  in  the 
early  stage,  and  before  the  disease  has  proceeded  far,  that  it  is 
possible  to  form  an  accurate  notion  of  the  characters  of  a tubercu- 
lated mass. 


1012 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Tlie  tubercular  masses  receive  not  injection,  and  hence  cannot 
be  said  to  receive  vessels  from  the  large  vessels  of  the  lungs.  At- 
tempts to  inject  tuherculated  lungs  were  made  by  Dr  William 
Stark ; and  he  always  found  that  the  injection  reached  neither  the 
vomicae  nor  the  tubercular  masses.  He  found  that  blood-vessels 
which  were  of  considerable  size,  at  a little  distance  from  a tuber- 
cular mass  or  masses,  speedily  became  contracted,  so  that  a large 
vessel,  which  at  its  origin  measured  nearly  half  an  inch  in  circum- 
ference, could  not  be  cut  open  further  than  an  inch ; and  that 
when  cut  open,  such  vessels  presented  a very  small  canal,  which 
was  filled  by  fibrous  substance,  evidently  albumen  or  coagulated 
blood.  The  same  fact  he  also  proved  by  blowing  air  into  the 
vessels,  or  injecting  them  with  wax.  When  air  is  blown  into  the 
vessels  of  a tuherculated  lung,  the  air  either  does  not  pass  along 
the  vessels  at  all,  or  does  so  in  a very  imperfect  manner,  nor  does 
air  in  this  manner  reach  the  vomicae.  If  coloured  wax  or  isinglass 
be  thrown  into  the  pulmonary  artery  and  vein,  the  parts  least 
aflPected  by  disease,  and  which  before  injection  are  soft  and  elastic, 
become  afterwards  the  hardest  and  firmest;  and  the  parts  most 
occupied  by  tubercular  masses,  and  which  before  injection  are 
hardest,  become  after  it  much  softer  than  the  others.  When  a 
lung  so  injected  is  divided  by  incision,  numerous  minute  branches 
filled  with  injected  matter  are  seen  in  the  sound  parts ; but  in  the 
diseased  parts,  few  or  no  injected  branches;  and  the  matter  is  ob- 
served never  or  seldom  to  enter  the  tuherculated  masses  or  their 
vomiccB. 

These  and  similar  experiments  were  performed  by  Schroeder, 
who  found  that  no  vessels  pass  through  the  centre  of  a vomica,  but 
are  closed,  and  as  it  were  truncated  at  the  margin  of  the  vomica ; 
that  in  cases  in  which  numerous  vessels  pass  transversely  across  a 
vomica  or  ulcer,  though  many  of  them  are  filled  with  wax,  when 
injected,  yet  the  small  or  capillary  branches  adhere  to  the  trunks 
externally  like  filaments,  or  in  the  form  of  slender  cellular  tissue, 
but  are  obstructed  and  impervious,  so  that  they  do  not  admit  the 
injected  matter;  whereas  the  trunks  penetrating  the  vomica  are 
surrounded  by  no  pulmonary  parenchyma,  excepting  the  filaments 
described  as  the  remains  of  the  capillary  vessels. 

From  these  facts  M.  Schroeder  concludes  that  the  obliteration 
begins  in  the  small  vessels  and  proceeds  to  the  large  trunks;  that 
this  obliteration  is  the  effect  of  inflammation  of  the  vasa  vasorum, 

4 


MORBID  STATES  OF  THE  LUNGS. — TUBERCLES.  1013 


by  which  lymph  is  effused  into  the  eanal  of  the  vessel  which  unites 
its  walls  and  renders  its  trunk  impervious ; that  the  vasa  vasorum 
may  not  be  so  much  affected  by  this  inflammation,  as  to  interrupt 
their  circulation,  and  may  continue,  consequently,  to  nourish  the 
obliterated  trunk,  which  then  forms  the  septum  of  Laennec,  and 
the  trabecula  of  Schroeder  ; but  that  in  those  instances  in  which 
these  nutrient  vessels  have  become  involved  in  the  inflammation 
and  obstructed,  the  trunk  becomes  black,  dies,  and  is  dissolved  in 
the  general  suppurative  destruction  of  the  tubercular  mass. 

The  state  of  the  lymphatic  vessels  it  is  extremely  difficult  to  dis- 
tinguish in  the  lungs ; and  though  M.  Schroeder  injected  with 
mercury  in  lungs  affected  with  vomicae,  some  lymphatic  vessels  of 
the  pulmonic  pleura,  yet  he  never  found  any  one  of  them  penetrat- 
ing the  substance  of  the  lung.  Subsequently,  however,  in  the 
sound  lung,  he  succeeded  not  only  in  injecting  with  mercury  the 
lymphatics  of  the  whole  surface  of  the  lung  (the  pulmonic  ^Zewra 
1 presume),  but  traced  several  branches  into  the  pulmonic  paren- 
chyma so  distinctly,  that  he  was  satisfied  that  the  lymphatics  en- 
compassed the  lobules  like  meshes  of  net-work  ; and  further  traced 
to  a small  black  tubercle  in  the  surface  of  the  lung,  not  far  from 
the  windpipe  several  lymphatic  vessels,  which  partly  penetrated  the 
tubercle,  and  partly  poured  mercury  into  it.  From  this  circum- 
stance, and  from  the  analogous  one,  that  tubercles  in  this  situation 
often  contain  calcareous  matter,  M.  Schroeder  thinks  it  not  un- 
unlikely,  that  the  calcareous  tubercles  are  the  result  of  degenera- 
tion of  the  lymphatic  vessels  or  glands. 

It  appears  that  the  nervous  filaments  terminate  with  the  vessels 
at  the  margin  of  the  vomica,  so  that  they  appear  to  have  been  con- 
verted into  a species  of  cartilage  or  tough  cellular  tissue.  In  one 
case  described  by  this  author,  the  nervous  branches  were  reddened 
and  thickened,  numerous  vessels  being  brought  into  view  upon 
them  by  means  of  injection.  Like  Mr  Swan,  M.  Schroeder  saw 
in  phthisical  persons  the  pneumogastric  nerve  reddened  and  thick- 
ened ; but  in  other  cases  he  admits  that  he  found  it  quite  unchang- 
ed, so  that  he  is  averse  to  make  any  positive  conclusion. 

Before  proceeding  to  describe  the  state  of  the  other  respiratory 
and  circulating  organs,  and  that  of  the  intestinal  canal,  it  is  pro- 
per to  consider  here  the  mode  in  which  these  tubercular  masses  are 
formed,  their  nature,  their  progress  and  progressive  changes,  and 
their  termination. 


1014 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


The  question  of  the  original  formation  of  tubercles  requires  the 
previous  consideration  of  three  points ; in  which  texture  of  the 
lungs  are  the  tubercular  bodies  first  deposited ; in  what  fornu 
fluid  or  solid,  are  they  first  deposited  ; and  what  is  the  cause  of  the 
deposition. 

1.  Dr  Stark  represents  tubercles  as  formations  in  the  filamento- 
cellular  substance  of  the  lungs  ; and  Baillie  inferred  from  dissec- 
tion, that  tubercles  were  deposited  in  the  cellular,  that  is  the  fila- 
mentous tissue  of  the  lungs.  This  opinion,  which  has  been  very 
generally  received  without  much  question  or  inquiry,  and  is  espous- 
ed by  Laennec,  derives  verisimilitude  from  the  appearances  pre- 
sented on  dissection  of  the  lungs  of  phthisical  persons,  in  which  in 
general  it  is  impossible  to  distinguish  anything  but  the  tubercular 
masses,  imbedded  as  it  were,  in  the  parenchyma  of  the  lungs.  We 
shall  see,  that,  in  order  to  obtain  just  views  on  this  point,  it  is  re- 
quisite to  examine  lungs  in  which  the  diseased  deposit  is  just  be- 
ginning, or  not  very  far  advanced,  or  very  generally  diffused 
through  the  lungs. 

2.  Another  opinion,  originating  in  the  idea  that  consumption 
is  a strumous  distemper,  and  that  strumous  distempers  are  seated 
in  the  lymphatic  system,  is  that  tubercles  are  morbid  formations  or 
a degeneration  of  the  lymphatic  glands  of  the  bronchi  and  lungs. 
This  opinion  has  been  more  or  less  strongly  maintained  by  Portal, 
Heberden,  Broussais,  and  Nasse.  “Upon  dissecting  the  bodies 
of  consumptive  persons,”  says  Heberden,  “ I have  seen  the  lung 
crowded  with  swelled  glands,  some  of  which  are  inflamed,  and  some 
suppurated  or  even  burst.”*  “ After  the  most  attentive  examina- 
tion,” says  Portal,  “ I think  that  the  tubercles  constituting  primary 
consumption  are  formed  both  by  enlargement  of  the  lymphatic 
glands  distributed  in  almost  all  the  parts  of  the  lungs,  or  remote 
from  the  bronchi,  and  also  by  lymphatic  swellings  of  the  cellular 
tissue  of  the  lungs,  which,  after  becoming  more  or  less  indurated, 
frequently  end  in  bad  suppuration.”! 

The  same  doctrine  has  been  not  less  explicity  and  forcibly  taught 
by  Broussais  in  several  of  his  writings  ; and  more  recently  by 
Nasse.! 

* Commentarii.  London,  1782. 

-f-  Observations  sur  la  Nature  et  le  Traitement  de  la  Phthisic  Pulmonaire,  Tome  ii. 
p.  309. 

J Horn’s  Archiv.  1824,  Juli,  Aug.  p.  106,  et  apurf  Rust  Plandbueh  der  Chirurgie, 
B.  xvi.  TuJjcrculosis,  p.  439. 


MORBID  STATES  OF  THE  LUNGS. — TUBERCLES.  1015 


The  gi’eat  objection  under  which  this  doctrine  labours,  is  its  be- 
ing at  variance  with  anatomical  facts.  The  lymphatic  bronchial 
glands  are  situate  chiefly  round  the  ramifications  of  the  bronchi ; 
and  though ' these  glands  are  sometimes  enlarged,  and  sometimes 
infiltrated  with  tyromatous  matter  in  young  subjects,  this  change 
is  not  uniformly  or  even  often  observed  in  pulmonary  consumption. 
The  bronchial  glands,  further,  may  be  affected  by  tyromatous  de- 
position, when  the  lungs  are  themselves  either  healthy,  or  at  least 
not  affected  by  tubercular  deposit.  Lastly,  in  those  instances  in 
which  the  bronchial  glands  are  enlarged,  indurated,  infiltrated  with 
tyromatous  matter,  or  softened  into  suppuration,  along  with  tuber- 
cular deposit,  and  tubercular  excavations  of  the  lungs,  the  former 
can  always  be  readily  distinguished  from  the  latter,  by  the  peculiar 
site  which  they  occupy,  and  still  more  by  their  appearance,  figure, 
and  other  physical  characters.  It  is  chiefly  in  children  that  this 
tyromatous  enlargement,  and  transformation  of  the  bronchial  glands 
is  observed ; and  in  those  cases  in  which  the  enlargement  is  asso- 
ciated with  tubercular  disease  of  the  lungs,  dissection  at  once  shows 
the  difference  between  the  two  lesions.  The  sections  of  the  bron- 
chial glands  are  large,  homogeneous,  circular,  or  elliptical,  whitish, 
or  grayish  coloured,  or  grayish-blue  surfaces  round  the  large  bron- 
chial tubes.  The  sections  of  the  tubercular  masses  are  irregular, 
variable  in  consistence ; hard  points  and  spots  being  mixed  with 
softer  portions,  and  the  colour  gray-blue,  or  bluish-red,  situate  in 
the  substance  of  the  pulmonic  lobes  and  lobules. 

As  the  affection  of  the  lymphatic  glands,  therefore,  is  not  ade- 
quate to  account  for  the  morbid  appearances  presented  by  phthisi- 
cal lungs.  Portal  admitted  that  tubercles  might  be  seated  in  other 
two  textures.  The  first  of  these  was  in  the  lymphatic  glands  of  the 
lungs,  properly  so  called,  which  are  smaller  than  the  bronchial 
glands,  more  regularly  rounded,  and  harder ; and  these  he  con- 
ceived became  the  seat  of  tubei’cular  infiltration  in  certain  forms  of 
consumption,  in  which  the  disease  began  by  plethoric  or  inflamma- 
tory symptoms. 

The  other  texture  in  which  he  admitted  that  tubercles  might 
be  formed,  is  the  cellular  or  filamentous  tissue  around  the  lympha- 
tic glands,  that  is,  the  parenchyma  of  the  lungs,  agreeing  in  this 
respect  with  Stark  and  Baillie.  This  takes  place,  however,  only 
under  particular  circumstances.  After  adverting  to  the  induration 
of  the  lungs  of  phthisical  persons,  and  their  increased  weight  above 


1016 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  average,  he  states  that  this  is  owing  to  the  extravasation  of 
glutinous  matter  (albuminous  matter,)  which,  after  filling  the  lym- 
phatic glands  and  the  lymphatic  vessels  terminating  in  them,  is  fur- 
ther extravasated  into  the  tissue  of  the  lungs,  and  forms  these  tu- 
bercles sometimes  in  infinite  numbers. 

Part  of  this  doctrine  seems  to  be  well  founded,  and  part  of  it  is 
perhaps  open  to  objection.  When  it  is  admitted  that  tubercles 
may  arise  from  extravasation  of  albuminous  matter  into  the  sub- 
stance of  the  lung,  the  exclusive  deposition  of  these  bodies  in  the 
bronchial  or  lymphatic  glands  is  virtually  abandoned.  The  only 
question  is,  whether  this  eflfusion  is  the  effect  of  the  preliminary 
abundance  of  fluid  in  the  glands  and  lymphatic  vessels ; and  whe- 
ther this  alleged  extravasation,  which  forms  tubercles  in  the  fila- 
mentous tissue  of  the  lungs,  may  not  take  place  without  affection 
of  the  glands,  and  does  not  take  place,  as  Broussais  seems  to  think, 
previously  to  that  affection  of  the  glands.  It  is  proper  to  add,  that 
M.  Andral  admits  that  this  mode  of  the  formation  of  tubercles  in 
the  lungs,  viz.  by  tubercular  matter  being  deposited  in  the  lympha- 
tic ganglions  of  the  interior  of  the  lung,  is  not  improbable.* 

3.  An  opinion,  which  appears  to  be  most  consonant  to  the  facts, 
is  that  which  was  brought  forward  in  1821  by  Magendie,  and  in  1826 
by  M.  Schroeder,  who  fix  the  seat  of  tubercular  deposition  in  the 
extremities  of  the  bronchial  tubes,  or  in  what  are  named  the  pul- 
monic vesicles,  in  which  the  tubercles  are  deposited  from  the  fine 
mucous  membrane  in  a state  of  inflammation. 

According  to  Magendie,  the  fii’st  indications  of  tubercular 
phthisis  consist  in  the  deposit  of  a certain  quantity  of  grayish-yel- 
low matter,  in  one  or  more  cells  of  the  lung.  The  yellow  matter 
sometimes  fills  completely  and  distends  the  cells ; but  it  is  easy  to 
perceive  the  small  blood-vessels  which  circumscribe  the  matter  de- 
posited. In  other  instances  the  yellow  matter  is  movable  within 
the  cells,  and  may  probably  be  expelled  from  them. 

In  some  instances  only  one  or  two  cells  contain  yellow  matter ; 
but  most  frequently  it  fills  all  the  cells,  forming  a lobule.  In  this 
case  the  matter  adheres  to  the  small  vessels ; and  these  soon  dis- 
appear ; on  which  the  whole  lobule  seems  formed  by  yellow  or  tu- 
bercular matter. 

After  opening  numerous  bodies,  M.  Magendie  never  saw  in  the 

* Clinique  Medicale,  Partie  iii.  sect.  iii. 


MORBID  STATES  OF  THE  LUNGS. — TUBERCLES.  1017 


cells  the  small  pearly  granules  which,  according  to  certain  authors, 
are  the  first  germs  of  phthisis.  On  the  contrary,  the  matter  first 
seen  is  that  named  tubercular  matter,  which  is  presented  as  if 
secreted  by  the  walls  of  the  small  pulmonary  blood-vessels.* 

These  views  on  the  first  origin  of  tubercular  deposition,  were 
afterwards  elaborated  and  illustrated  by  M.  Schroeder  and  Dr 
Carsewell;  and  they  seem  from  various  facts  to  he  most  pro- 
bable. 

In  order  to  form  a clear  conception  of  the  origin  of  the  process 
of  tubercular  deposition  in  the  lungs,  it  is  necessary  to  examine 
these  organs  in  the  bodies  of  persons  cut  off  by  other  diseases,  and 
in  the  earlier  stages  of  consumption,  when  the  disease  has  made 
little  progress.  At  this  stage  of  the  disease  it  is  still  uncomplicated 
with  mai'ks  of  general  inflammation  of  the  lung,  or  its  component 
tissues  ; and  at  the  worst  there  is  merely  topical  change. 

If  in  this  state  tubercles  he  divided  and  inspected  by  the  aid  of 
the  microscope,  it  then  appears  that  the  air-cells  of  the  lungs  are 
filled  with  some  opaque  material,  which  renders  them  less  pellucid, 
the  nearer  the  eye  is  directed  to  the  edge  of  the  tubercles.  The 
cells  filled  with  pellucid  coagulable  lymph  are  harder  than  the 
neighbouring  sound  cells,  and  do  not  admit  the  air,  as  easily  ap- 
pears by  slight  pressure  in  water.  This  lymph  contained  in  the 
cells  is  sometimes  so  limpid,  that  the  tubercle  can  scarcely  be  dis- 
tinguished by  the  eye  from  the  sound  structure  of  the  lung,  and 
requires  the  aid  of  touch. 

In  other  spots,  however,  the  centre  of  the  tubercle  is  already 
white,  and  losing  its  transparency,  has  become  opaque ; so  that  by 
the  aid  of  the  microscope,  in  the  centre  of  the  cell  little  or  nothing 
can  be  distinguished,  and  their  parietes  appear  united  with  the 
matter  of  the  tubercle,  while  the  adjoining  cells  still  contain  trans- 
parent matter.  From  this  fact  the  author  infers,  in  opposition  to 
the  representation  of  Laennec  and  Lorinzer,  that  in  certain  air-cells, 
or  in  a lobule  of  the  lung,  local  inflammation  may  be  developed, 
and  produce  effusion  of  lymph  which  obstructs  the  air-cells. 

As  this  exudation  proceeds,  the  walls  of  the  cells  are  at  length 
compressed  on  all  sides,  and  not  only  unite  with  the  contained 
lymph ; but,  as  the  effusion  hardens  and  becomes  opaque  princi- 

* Memoire  sur  la  structure  du  poumon  de  Phoinme,  &c.  &c.,  et  sur  la  premiere  ori- 
gine  de  la  phthisie  pulmonaire  ; par  M.  Magendie.  Journal  de  Physiologie,  Tome 
I.  p.  78.  Paris,  1821. 


1018 


GENERAL  AND  rATHOLOGICAL  ANATOMY. 


pally  from  the  centre  to  the  circumference,  a mass  of  lung  thus 
occupied  becomes  solid  and  granular  in  the  centre,  and  softer  at 
its  margins. 

The  shape  of  the  tubercular  mass  thus  formed  depends  on  the 
sti’ucture  of  the  lung, — a circumstance  on  which  authors  have  not 
bestowed  sufficient  attention.  The  lobes  of  the  lungs  consist  of 
lobules  united  by  cellular  tissue  ; and  each  lobule  receives  a sepa- 
rate bronchial  tube,  which  terminates  in  many  air-cells,  all  pervious 
to  air, — and  a peculiar  artery  and  vein,  each  subdivided  into  many 
minute  vessels,  all  penetrable  by  injected  fluids  in  the  sound  state.  It 
hence  results  that  the  beginning  of  tubercular  deposition  is  confined 
at  first  to  one  lobule  only,  without  affecting  the  contiguous  lobules, 
and  is  recognized  only  by  the  greater  opacity  and  firmness  of  that 
lobule  than  of  the  healthy  ones.  It  is  also  found,  by  injecting  the 
arteries  and  veins  of  the  lung,  that  some  lobules  are  less  penetrated 
with  this  tubercular  deposition  than  others,  the  vessels  of  the  for- 
mer being  more  susceptible  of  injection,  while  those  of  the  latter 
are  few  in  number  and  less  penetrable  by  injection,  and  diminish 
in  this  manner  in  number  and  susceptibility  of  injection,  till  in  the 
truly  and  perfectly  tuberculated  lobule  the  small  vessels  are  com- 
pletely shut  and  obliterated,  and  the  large  one  only  remains  per- 
vious. In  such  lobules  the  structure  of  the  lung  can  no  longer  be 
traced ; the  shape  of  the  air-cells  is  destroyed ; and  in  the  centre 
of  these  tuberculated  lobules,  which  is  hollow,  suppuration  has 
commenced.  Such  tuberculated  lobules  are  whiter  than  the  ad- 
joining ones,  and  are  surrounded  by  thick  cellular  tissue  separating 
them  from  the  adjoining  lobules,  which  may  at  this  stage  of  the 
disease  be  less  affected.  Very  soon,  however,  the  air-cells  of  these 
lobules  become  penetrated  by  the  same  deposition,  which  in  like 
manner  becomes  opaque  and  firm,  and  agglutinates  the  cells  into  a 
similar  firm,  inelastic  mass,  also  surrounded  by  indurated  filamen- 
tous tissue.  When  at  length  several  lobules  have  in  this  manner 
become  penetrated  and  occupied  by  tubercular  deposition,  with  the 
suppurative  destruction  proceeding  in  their  respective  centres,  the 
coalescence  into  a single  undistinguishable  mass  is  followed  by  the 
union  of  their  i*espective  minute  cavities  into  one  or  more  larger 
ones.  In  the  course  of  this  process,  the  cellular,  or  rather  what 
I term  the  filamentous,  tissue  of  the  lung  being  placed  outside  the 
penetrated  cells,  naturally  resists  longest  the  suppurative  process, 

and  may  even  become  thickened  and  indurated.  At  length,  how- 

6 


MORBID  STATES  OF  THE  LUNGS. — TUBERCLES.  1019 


ever,  this  also  may  give  way,  and  be  destroyed  partially  or  entirely; 
and  hence  appears  the  reason  why  some  anatomists  maintain  that 
the  tubercle  or  small  vomica  is  surrounded  by  a membrane,  while 
by  others  this  is  denied. 

From  this  account  of  the  progressive  formation  of  tubercles,  it 
results  that  not  only  the  air-cells  are  filled,  and  then  obliterated  by 
the  exudation  of  coagulable  lymph,  but  that  the  areas  of  the  blood- 
vessels are  so  contracted,  that  they  no  longer  admit  the  wax  of  in- 
jection, and  become  obliterated,  and  incapable  of  receiving  and 
conveying  blood  to  the  ultimate  terminations  ; and  hence  the  cen- 
tre of  the  tubercle  wastes,  and  is  consumed  and  degenerated ; and 
that  the  vessels,  still  pervious,  assuming  the  inflammatory  action, 
secrete  purulent  matter,  which  dissolves  the  tubercle  already  soft- 
ened and  macerated.  M.  Schroeder  van  der  Kolk  further  regards 
this  deposition  as  coagulable  lymph,  because  by  immersion  in  spirit 
it  is  coagulated  and  rendered  opaque ; and  he  therefore  contends 
that  it  is  impossible  to  adopt  the  view  of  Laennec  and  Lorinzer, 
or  Nasse,  that  tubercles  are  formed  without  previous  inflammation. 
The  argument  also  adduced  by  the  latter  author,  that  tubercular 
deposition  takes  place  generally  in  the  upper  lobe  of  the  lung, 
whereas  peripneumony  occurs  more  frequently  in  the  lower  one, 
he  thinks  of  no  moment.  He  admits  the  fact,  but  maintains  that 
it  merely  shows  that  tubercular  deposition  and  the  consequent  vo- 
miccB  diflPer  from  peripneumony,  and  that  chronic  inflammation  dif- 
fers from  the  acute  form  of  the  disease. 

The  question  regarding  the  origin  of  tubercles  from  degenerated 
bronchial  glands,  he  allows  to  be  more  difficult  of  decision, — from 
the  fact,  that  frequently  degeneration  and  inflammation  of  the 
glands  of  the  neck,  or  some  other  part,  precede  the  appearance  of 
consumption,  and  that  strumous  persons  are  very  liable  to  the  dis- 
ease. He  observes,  however,  that  in  examining  carefully  the  bo- 
dies of  the  strumous,  when  the  vessels  were  filled  with  fine  injection, 
he  found  very  minute  tubercles  occupied  in  different  points  by  con- 
cretions, and  in  general  calcareous  rather  than  tubercular  matter 
deposited.  In  examining  such  lungs  microscopically,  he  found  the 
minute  branches  of  the  bronchial  tubes,  at  least  to  one-fourth  of  a 
line  in  diameter,  everywhere  reddened  within  by  injected  vessels, 
and  a beautiful  net-work  expanded  on  the  internal  mucous  mem- 
brane ; in  some  of  the  minute  branches,  he  saw  the  smaller  glands 
thick  and  somewhat  whiter  ; the  miliary  tubercles  were  surrounded 


1020 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


by  a net-work  of  vessels,  in  which  he  could  distinguish  the  air-cells 
still  open.  These  tubercles  generally  adhered  externally  to  the 
branches  of  the  bronchial  tubes,  or  to  the  pulmonary  arteries  and 
veins ; in  some  cases  a small  bronchial  tube  seemed  to  end  in  a 
tubercle.  Externally  the  pulmonic  pleura  was  marked  by  black 
round  lines  like  rings,  which  appeared  to  be  lymphatic  vessels. 
Where  the  degeneration  was  a little  greater,  the  cells  were  oblite- 
rated, and  the  tubercles,  the  vessels  of  which  were  impervious,  ap- 
peared to  have  coalesced  into  a whitish  mass. 

This  author  doubts,  nevertheless,  whether  these  bodies,  which  he 
denominates  miliary  tubercles,  were  not  obliterated  vessels,  which, 
when  cut  across,  presented  the  appearance,  but  had  not  the  reality 
of  tubercles,  the  more  so,  that  these  tubercles  could  be  traced 
through  the  lungs  in  the  direction  of  ramification.  He  further  ex- 
presses the  opinion,  that  these  tubercles  are  first  formed  by  thicken- 
ing, and  inflammatory  degeneration  of  lymphatic  glands,  and  that 
this  is  the  reason  why  they  present  a different  appearance  from  that 
of  the  ordinary  tubercles  of  the  air-cells  already  described, — since 
they  seem  to  adhere  most  to  the  small  bronchial  tubes. 

As  to  the  origin  of  the  calcareous  matter,  he  does  not  admit  that 
these  concretions  can  be  formed  by  the  inhalation  of  dust  or  sand, 
since  their  structure  is  too  complex,  and  the  opinion  is  sufficiently 
refuted  by  analysis  ; but  he  thinks,  that  the  surrounding  membrane, 
whether  that  of  a gland,  or  an  air-cell,  had  so  degenerated  by  in- 
flammation as  to  assume  the  fibrous  character,  and  the  faculty  of  osse- 
ous or  calcareous  secretion. 

He  infers,  therefore,  that  the  lungs  present  two  kinds  of  tu- 
bercles ; one  produced  by  chronic  inflammation  of  the  air-cells,  by 
which  their  membrane  is  made  to  secrete  lymph,  which  fills  and 
unites  them  into  a mass ; the  other  more  calcareous,  produced  ap- 
parently by  degeneration  of  the  minute  glands  ; but  both  agreeing 
in  inducing  inflammation  of  the  adjoining  air-cells,  and  vomicae. 
The  suppuration  which  produces  the  latter  change,  and  which  com- 
mences most  frequently  in  the  centre,  though  sometimes  in  the  side 
of  the  tubercle,  presents  this  peculiar  difference  from  common  sup- 
puration, or  that  which  takes  place  in  wounds,  that  whereas  in  the 
latter  granulations  are  formed  by  which  the  cavity  is  filled,  in  the 
former  no  granulations  take  place,  because  no  new  vessels  are 
formed ; and  as  the  vessels  are  obstructed  and  convey  no  new 
matter,  the  tubercular  mass  is  softened  by  a species  of  partial  death. 
When  this  suppurative  destruction  begins,  it  proceeds  in  general 


MORBID  STATES  OF  THE  LUNGS. — TUBERCLES. 


1021 


till  the  tubercular  mass  is  broken  down  and  excavated ; and  it  is 
much  less  common  to  find  a tubercle  partly  dissolved  than  entire, 
or  a small  vomica^  after  the  tubercle  has  been  destroyed  by  sup- 
puration. In  this  state  the  vomica  is  lined  by  a thin  vascular 
membrane,  sometimes  by  a thick  yellowish  one ; and  if  small,  it  is 
rarely  traversed  by  any  vessel ; but  this  is  not  unusual  in  large 
vomiccs.  The  author  also  observes,  that  these  tubercular  masses 
afford,  in  the  process  of  softening,  an  illustration  of  the  general 
principle  formerly  laid  down,  that  every  inflamed  part  and  ulcer 
presents  at  the  same  time  different  degrees  of  inflammation.  The 
centre  of  the  tubercle  may  be  dead  or  expelled  after  the  process 
of  solution  ; its  crust  may  be  in  a state  of  suppurative  softening  ; 
the  circumference  may  be  inflamed ; and  this  process  diminishes  in 
the  parts  of  the  lung  farthest  removed  from  the  margin  of  the  air- 
cells. 

In  the  manner  now  mentioned,  the  cavity  of  a vomica  is  progres- 
sively enlarged,  until  in  desperate  cases  of  consumption  the  patient 
sinks  under  the  disease.  The  extent  to  which  the  lung  is  destroyed 
before  this  event  takes  place,  varies  according  to  the  age  of  the 
parties. 

Similar  views  of  the  mode  in  which  tubercles  are  originally  de- 
posited in  the  lungs  have  been  taken  by  M.  Andral,  Dr  Carsewell, 
M.  Ravin,*  and  other  pathologists.  The  bronchial  tubes  terminate 
in  shut  sacs,  lined  by  a fine  mucous  membrane,  and  enclosed  by  the 
submucous  or  filamentous  tissue.  This  fine  mucous  membrane  is 
liable  to  various  forms  of  inflammation,  in  which  it  secretes  a fluid 
or  semifluid  matter  which  contains  much  albumen,  and  conse- 
quently is  liable  to  undergo  spontaneous  coagulation.  This  has 
been  sometimes  named  strumous  matter,  glutinous  matter,  (Portal,) 
plastic  lymph,  (Schroeder,)  coagulable  lymph,  purulent  matter  of 
particular  nature,  (Lerminier  and  Andi’al,)  and  tubercular  matter. 
None  of  these  denominations  convey  a just  notion  of  the  object; 
and  the  latter  is  objectionable,  because  it  is  applied  indiscrimi- 
nately to  several  kinds  of  morbid  texture,  different  both  in  nature 
and  in  form.  But  it  is  sufiicient  to  know  that  the  mucous  mem- 
brane of  these  bronchial  terminations  or  vesicles  is  liable  to  a kind 
or  form  of  inflammation,  which  is  perhaps  peculiar,  and  that  in  this 
state  it  secretes  matter,  which,  though  at  first  fluid,  afterwards  be- 

• Memoire  sur  les  Tubercules,  pour  repondre  a la  question  proposee  par  I’Academie 
Royale  de  Medecine  dans  28  Aout  1827.  Par  F.  P.  Ravin,  D.  M.,  &c.  Memoires 
de  I’Academie  Royale  de  Medecine,  Tome  IV.  Paris  1835,  p.  324. 


1022 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


comes  solid,  filling  up  and  obstructing  the  terminations  of  the  tubes. 
As  the  matters  effused  become  solid,  they  naturally  assume  the 
rounded  or  oblong-rounded  form  of  the  pulmonic  vesicles ; and  in 
this  state,  as  they  are  small,  firm,  rounded  bodies,  harder  than  the 
neighbouring  parts,  and  giving  them  a knotty  appearance,  they  are 
tubercles  {tuhercula),  or  little  tuberosities. 

That  this  is  one  and  perhaps  the  most  usual  mode  in  which 
tubercles  are  formed,  must  be  regarded  as  established  by  the  accu- 
rate and  beautiful  delineations  of  Dr  Carsewell,  who  has  repre- 
sented the  tubercular  matter,  as  he  terms  it,  when  deposited  on  the 
free  surface  of  the  bronchial  mucous  membrane,  at  the  extre- 
mities of  the  bronchial  tubes.  Andral  manifestly  takes  the  same 
view  of  one  of  the  modes  in  which  pulmonary  tubercles  may  be 
formed. 

Frederic  Peter  Ludovic  Cerutti,  who  published  in  1839  a short 
but  learned  dissertation  on  the  subject,  states,  that  after  repeated 
observations,  he  had  not  been  able  to  satisfy  himself  of  the  facts 
adduced  by  Schroeder ; but  allows  it  to  be  proved  that  the  cells 
of  the  lung  in  those  parts  becoming  occupied  by  tubercular  matter, 
and  which  differ  from  healthy  cells,  in  presenting  a different  colour, 
contain  no  air,  because  not  only  individual  portions  of  lung  sink  in 
water,  but  also  a whole  lobe,  which  still  fresh,  on  being  immersed 
in  w'ater,  sunk  more  than  one-half,  immediately  after  being  inflated 
by  air,  rose  to  the  surface. 

From  this  fact,  he  is  convinced  that  tubercles  in  their  origin 
consist  of  a fluid  exudation,  which  moistens  the  walls  of  the  pulmonic 
cells,  which,  he  argues,  are  mutually  compressed  by  the  increased 
weight  caused  by  this  humidity,  to  such  a degree  only,  that  though 
the  inspired  air  is  unable  to  enter  them,  they  may  nevertheless  be 
expanded  by  artificial  inflation.* 

In  the  first  commencement  of  this  distemper,  the  colour  of  the 
affected  portion  of  the  lung  only  is  changed ; and  as  yet  the  secreted 
matter  is  probably  soft  and  semifluid,  or  at  least  not  very  firm. 
But  after  some  time,  when  the  effused  matter  has  acquired  consis- 
tence, and  become  a little  firm,  the  part  is  felt  between  the  fingers  as 
if  it  contained  several  hard  knots.  These  are  granular  or  graniform 
bodies  within  the  air  cells,  filling,  distending,  and  preventing  them 

* Collectanea  quaedam  de  Phthisi  Pulmonum  tuberculosa  scripsit  et  in  Uiiiversi- 
tate  Lipsiae  in  die  xviii.  .Tunii  A.  C.  1839,  publice  defendet,  Dr  Frid.  Petrus  Ludovi- 
cus  Cerutti,  Pathologi®  et  Therapiae  Specialis,  P.  P.  0.  Des.  Lipsiae,  183.9.  4to, 

p.  22. 


MORBID  STATES  OF  THE  LUNGS.— TUBERCLES.  1023 

from  collapsing.  The  size  of  these  bodies  in  this  stage  is  about 
that  of  a pin-head,  rising  to  a millet-seed  or  a grain  of  mustard- 
seed.  These  bodies,  now  described,  have  been,  in  this  state,  re- 
garded as  the  miliary  tubercles  of  Bayle  and  Laennec,  the  dissemi- 
nated tubercles  of  Gendrin,  and  the  simple  tubercles  of  Dr  Lombard 
and  Dr  Home.  But  this  does  not  appear  to  be  established  with 
unquestionable  certainty.  One  variety,  at  least,  of  the  miliary 
tubercle,  I am  inclined  to  think,  is  formed  in  the  filamentous  tissue 
of  the  lungs ; and  certainly  differs  widely  from  the  arrangement 
and  appearance  of  the  bodies  now  mentioned. 

A good  method  of  demonstrating  the  origin  of  the  most  usual 
forms  of  pulmonary  tubercles,  is  by  observing  what  takes  place  in 
lobular  pneumonia.  In  this  disease  inflammation  attacks  the  lung 
in  individual  lobules,  perhaps  beginning  first  like  vesicular  hron- 
cJiitis,  that  is,  affecting  the  terminations  of  the  bronchial  tubes,  and 
the  air  cells,  and  perhaps  in  a slight  degree  the  submucous  fila- 
mentous tissue,  or  the  parenchyma  of  the  lung  in  which  these  vesi- 
cles are  imbedded.  The  result  of  this  inflammation  is  effusion 
within  the  vesicles  of  a species  of  soft  semifluid  matter,  intermediate 
between  albumen  and  gelatine,  but  which  undergoes  coagulation, 
and  thereby  fills  the  vesicles  with  an  equal  number  of  small  round- 
ish bodies,  of  moderate  consistence,  but  which  eventually  become 
firm,  and  at  length  hard,  while  their  mutual  proximity  aggregates 
them  together  into  small  hard  masses,  isolated,  and  limited  to  each 
pulmonary  lobule,  or  part  only  of  a lobule.  As  the  disease  proceeds, 
it  affects  the  whole  lobule,  and  its  investing  tissue  or  capsule,  giv- 
ing it  the  appearance  of  a hard  knotty  mass,  irregular  in  shape  and 
figure,  and  surrounded  by  natural  pulmonic  tissue.  This  disease 
may  either  affect  one  or  two,  or  many  lobules  simultaneously  and 
successively ; and  in  proportion  to  the  extent  over  which  it  is  dif- 
fused, the  lung  is  occupied  by  bodies  having  all  the  characters  of 
tubercles,  and  which  eventually  constitute  pulmonary  tubercles. 

In  this  state,  these  masses,  when  divided,  are  firm,  of  a bluish- 
gray  colour,  and  consist  of  minute  portions  aggregated  together, 
in  a confused  manner,  so  as  to  form  a mass  not  quite  homogeneous, 
but  firmer  than  the  surrounding  lung.  In  this  state,  before  these 
masses  have  become  softened,  they  constitute  what  has  been  named 
by  Laennec  crude  or  yellowish  tubercles  {tuber cula  cruda)^  ^^gglo- 
merated  tubercle  by  Gendrin,  multiple  tubercle  by  Lombard,  and 
aggregated  tubercle  by  Dr  Home.  These  masses  vary  in  size. 


1024 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


from  that  of  a garden  pea  or  a cherry-stone,  to  that  of  a walnut  or 
even  larger.  Though  the  surrounding  lung  may  be  sound,  yet 
the  portions  of  lung  which  previously  were  in  the  place  of  these 
tubercular  masses  are  completely  solidified;  and  hence  neither 
bronchial  tubes  nor  blood-vessels  are  traced  into  them. 

Another  lesion,  which  has  been  believed  to  form  a certain  stage 
of  this  process  of  the  conversion  of  isolated  or  simple  tubercles 
into  aggregated  tubercles,  is  that  which  has  been  named  gray, 
semitransparent  granulations,  and  which,  indeed,  are  the  miliary 
or  cartilaginous  tubercles  of  Bayle.  It  is  certain,  both  from  the 
researches  of  Dr  Carsewell,  Andral,  and  Cerutti,  that  they  may 
exist  in  the  lungs  without  giving  rise  to  the  peculiar  structure 
already  described  as  tubercular.  They  are  generally  isolated,  very 
seldom  aggregated,  disseminated  or  dispersed  through  the  lungs 
almost  indiscriminately  ; and  it  is  very  doubtful  whether,  if  they  be 
formed  in  the  air-cells,  they  are  always  formed  in  them. 

Andral  regards  these  gray  granulations  as  indurated  and  hyper- 
trophied air  cells.  I have  several  times  observed  them  in  the  fila- 
mentous tissue  of  the  lung,  in  such  circumstances  that  I thought  it 
scarcely  possible  for  them  to  be  formed  in  the  cells.  In  some  in- 
stances they  appear  like  transformation  of  certain  portions  of  the 
lymphatic  vessels  or  glands  of  the  lungs.  They  are  occasionally 
observed  in  tbe  lungs  of  quarry-men,  stone-cutters,  and  hewing- 
masons. 

In  certain  cases,  however,  of  this  sort  of  lesion,  it  has  been  as- 
certained that  these  gray,  semitransparent,  hard  tubercles  are  de- 
posited originally  in  the  pulmonic  vesicles.  Thus,  Dr  Home  men- 
tions that  a specimen  of  this  kind  of  tubercle,  occurring  in  a bew- 
ing-mason,  was  presented  in  1838  to  the  Anatomical  Society,  in 
which  it  was  found  that  in  the  centre  of  each  tubercle  was  contained 
a grain  of  sand  or  earthy  matter,  ascertained  to  consist  of  silica  and 
carbonate  of  lime,  and  which  had  no  doubt  been  inhaled,  and  gave 
rise,  by  mechanical  irritation,  to  chronic  inflammation  in  the  ends 
of  the  bronchial  tubes. 

A third  lesion,  which  has  been  sometimes  rather  vaguely  called 
tubercular,  is  what  may  be  termed  gray  hepatization,  occurring  in 
definite  masses,  or  circumscribed  gray  hepatization,  or,  what  might 
be  less  objectionable,  circumscribed  tyromatous  deposition. 

In  this  state,  a portion  of  lung,  more  or  less  extensive,  becomes 
tbe  seat  of  considerable  induration  and  solidification  ; and  when  a 


MORBID  STATES  OF  THE  LUNGS. — TUBERCLES.  1025 


portion  thus  affected  is  divided,  it  is  observed  to  consist  of  various 
minute,  gray-coloured,  firm  bodies  or  grains  aggregated  together, 
and  which  give  the  section  a gray  or  light-yellow  colour,  and  a 
granular  aspect.  There  is  no  doubt  that  this  change  in  the  con- 
sistence and  appearance  of  the  lung  is  the  effect  of  inflammation, 
acute,  subacute,  or  chronic ; but  it  is  not  quite  certain  that  the  pre- 
sence of  this  state  is  a necessary  step  in  the  formation  of  tubercles. 
This  change  may  probably  take  place  in  any  part  of  the  lung ; but 
the  situations  in  which  I have  most  usually  seen  it  are  the  upper 
lobe  near  its  apex,  and  sometimes  the  middle  lobe  of  the  right  side. 
This  has  been  observed  by  Baillie,  and  is  described  by  Laennec, 
under  the  name  of  tubercular  infiltration,  and  by  Dr  Home  under 
the  name  of  diffuse  tubercle. 

In  this  form  of  the  disorder,  the  morbid  deposition  does  not  be- 
gin in  the  air-cells  exclusively,  as  in  the  first  described,  but  affects 
all  the  elementary  tissues  of  the  luug  by  lobules,  at  once  in  one  uni- 
form disorder ; and  it  gives  rise  to  extravasation  of  albuminous  or 
tyromatous  matter,  over  the  whole  space  which  it  affects,  but  effused 
into  the  cells  and  filamentous  tissue,  and  compressing  and  thereby 
obliterating  the  air  vesicles,  the  tubes,  and  the  blood-vessels  all  at 
once.  Often  also  the  surrounding  tissue  of  the  lobule  is  converted 
into  a sort  of  membrane  or  capsule,  so  that  the  tyromatous  deposit 
appears  as  it  were  encysted.  The  size  which  these  masses  acquire, 
varies  from  that  of  a small  gooseberry  to  a large  one  or  more. 
When  divided,  besides  the  yellow  or  gray  colour  already  mentioned, 
they  present  a much  more  uniform  or  homogeneous  aspect  than  the 
other  forms  of  tubercular  deposit. 

The  state  of  the  surrounding  lung,  though  often  congested  or 
reddened,  varies  much  both  in  these  different  forms  of  deposition 
and  also  in  different  stages  of  its  progress.  In  the  early  stage,  or 
that  of  crudity,  the  substance  of  the  lung  around  may  be  crepitat- 
ing, elastic,  and  compressible ; and  even  in  the  advanced  stage, 
some  observers  have  found  the  lung  interposed  and  surrounding, 
free  from  induration  or  much  redness.  Thus  Baillie  and  Soemmer- 
ing found  the  substance  of  the  lung  surrounding  considerable  tu- 
bercular masses  healthy  ; and  Laennec  and  Louis  appear  to  have 
observed  the  same  fact.  Much  more  frequently,  however,  there 
are  more  or  less  reddening,  vascular  congestion,  and  infiltration  of 
serum  into  the  substance  of  the  lung ; and  in  a considerable  num- 
ber of  cases  I have  observed  pneumonic  inflammation  either  in  its 
first  or  in  its  second  stage. 

3 T 


1026 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


In  the  case  of  the  isolated  tubercular  infiltration,  chronic  pneu- 
monia is  very  common.  At  least  in  the  cases  of  that  form  which 
have  fallen  under  my  own  observation,  I have  observed,  that  symp- 
toms altogether  like  those  of  pneumonia  or  peripneumony  took 
place  during  life,  and,  upon  inspection  after  death,  the  usual  ap- 
pearances left  by  inflammation  of  tbe  substance  of  the  lung  were 
found.*  These  tubercles,  indeed,  do  not  appear  readily  to  under- 
go the  process  of  softening,  and  most  usually  prove  fatal  either  by 
being  complicated  with  or  inducing  pneumonic  inflammation. 

It  may  be  here  mentioned,  that,  both  in  simple  red  or  brown  and 
gray  consolidation,  and  when  these  changes  are  accompanied  by 
the  presence  of  tubercles,  fat-globules  and  adipose  particles  may  be 
recognized. 

The  manner  in  which  tubercular  masses  are  softened  or  broken 
down  and  discharged,  or  what  may  be  termed  tbe  mechanism  of 
tubercular  softening  and  excavation,  has  attracted  some  notice, 
and  deserves  consideration.  At  one  time,  it  was  imagined  to  be 
either  identical  with,  or  analogous  to,  suppuration  in  other  tissues; 
and  it  was  supposed  that  tubercular  vomica  were  merely  abscesses 
of  the  lungs.  But  the  process,  though  perhaps  analogous  to,  is  not 
the  same  with  suppuration.  It  seems  to  be  more  complicated,  and 
not  so  uniform  in  its  progress.  It  seems  to  be  difficult  to  ascertain 
at  what  part  softening  commences.  In  one  case  it  may  begin  in 
the  centre,  and  proceed  to  the  circumference ; in  another  it  may 
begin  at  tbe  circumference,  and  go  round  the  whole  mass,  detach- 
ing it  from  the  surrounding  lung ; in  a third  case  it  may  begin  at 
once  at  the  centre,  and  at  the  margins ; and,  in  other  cases,  it  has 
been  observed  to  commence  at  the  same  time  in  several  parts  of  the 
substance  of  the  tubercular  mass.  The  latter  is  tbe  course,  especi- 
ally in  the  case  of  large  tubercular  masses.  Cerutti,f  who  enter- 
tains this  opinion,  states  that,  in  the  section  of  a tubercular  mass 
in  this  state,  the  portion  or  spots  about  to  be  softened  appear  to 
lose  firmness  and  to  become  friable,  and,  if  examined  by  the  mi- 
croscope, they  present  numerous  minute  holes,  as  if  punctured  by  a 
needle.  This  condition  extends  over  the  -whole  mass,  until  its 
parts  are  detached  from  each  other ; and  minute  grains  are  found 
amidst  a semifluid  or  fluid  opaque  mass.  While  this  is  proceeding, 

* Two  Cases  of  Tubercular  Deposition,  &c.  By  D.  Craigie,  M.D.  Edin.  Med.  and 
Surg.  Journal,  Vol.  xliii.  jr.  273. 

-j-  Collectanea  quaedam  de  Phthisi  Pulmonum  tubereulosa  scripsit  et  in  Universitate 
Lipsiae  in  die  xviii.  Junii  A.  C.  1839,  publice  defendet,  Dr  Frid.  Petrus  Ludovicus 
Cerutti,  Pathologiae  et  Therapiae  Specialis,  P.  P.  O.  Des.  Lipsiae,  1839,  4to,  p.  22. 


MORBID  STATES  OF  THE  LUNGS  IN  CONSUMPTION.  1027 


a communication  is  established  with  one  or  more  bronchial  tubes, 
the  small  end  of  which  are  destroyed  or  dissolved  in  the  soften- 
ing process,  and  the  semifluid  matter  reaching  them  irritates  them, 
causing  secondary  catarrh,  and  excites  coughing,  hy  which  it  is  ex- 
pelled. The  transition  of  this  semifluid  matter  through  the  bron- 
chial tubes  is  the  cause  of  the  redness  and  villous  appearance  of  the 
mucous  membrane  of  the  bronchial  tubes,  so  generally  observed  in 
the  lungs  of  those  destroyed  by  this  distemper. 

On  the  means  by  which  this  softening  is  effected,  different  opini- 
ons have  been  entertained.  An  opinion  very  generally  received  is, 
that  the  tubercular  masses,  acting  in  some  manner  as  foreign  bodies, 
give  rise  to  irritation  and  vascular  action  in  their  vicinity,  and 
thereby  induce  a sort  of  congestive  and  inflammatory  afflux  of  fluids, 
in  which  they  are  dissolved  in  imperfect  suppuration.  This  opinion 
is  supported  by  those  facts  which  show  that  tubercles  begin  to  sof- 
ten near  the  circumference  of  the  masses. 

Many  tubercular  masses,  nevertheless,  seem  to  possess  an  inter- 
nal and  innate  tendency  to  destruction.  Their  texture  is  imperfect  ;* 
and  in  some  instances  the  internal  substance  begins  to  soften,  ap- 
parently whether  any  irritation  of  the  surrounding  lung  has  taken 
place  or  not.  There  is  no  doubt  that,  in  a considerable  proportion 
of  cases,  the  presence  of  the  irritation  of  severe  bronchitis  or  peripneu- 
mony  appears  to  have  pushed  the  tubercular  masses  into  speedy  li- 
quefaction ; and  the  frequency  with  which  the  symptoms  of  pneu- 
monic inflammation  are  succeeded  by  those  of  consumption,  shows 
that  in  the  formation  of  softening  at  least,  if  not  in  the  develop- 
ment of  tubercular  deposits,  inflammatory  congestion  has  great 
influence. 

As  softening  proceeds,  whether  it  has  been  attended  with  pneu- 
monic inflammation  or  not,  it  is  speedily  followed  by  that,  and  by 
bronchial  inflammation,  the  latter  being  chiefly  induced  and  main- 
tained by  the  incessant  irritation  kept  up  by  the  transition  over  the 
membrane  of  the  contents  of  the  tubercular  softening.  If  the  tu- 
bercular mass  be  large,  or  if  the  degree  of  pneumonic  inflammation 
be  considerable,  it  affects  a third  membrane,  viz.  the  pleura.  In 
all  cases,  indeed,  in  proportion  to  the  size  of  tubercular  mass,  and 
the  consequent  excavation  to  be  formed,  and  as  that  advances  from 
the  substance  to  the  surface  of  the  lungs,  pleurisy  takes  place.  The 


* See  p.  1012. 


1208 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


great  use  of  this  inflammation,  or  what  may  be  termed  its  final 
cause,  in  the  softening  and  expulsion  of  tubercular  masses,  is,  by 
the  effusion  of  lymph  and  the  formation  of  adhesions  between  the 
pulmonic  and  costal  pleura,  to  prevent  perforation  of  the  lung,  the 
escape  of  air  and  tubercular  matter  into  the  cavity  of  the  pleura 
{pneumothorax,  and  empyema),  and  the  consequent  formation  of 
pleurisy  complicated  with  pneumothorax, — a lesion  generally  fatal. 
By  the  slow  and  gradually  advancing  inflammation  of  the  pleura, 
and  the  consequent  albuminous  exudation  and  adhesion,  this  acci- 
dent is  prevented.  This  is  so  common,  that  in  one  case  only  among 
112  were  the  lungs  free  of  adhesions. 

It,  nevertheless,  sometimes  happens  that  this  accident  takes 
place.  The  apex  of  the  lung,  I have  already  said,  is  very  gene- 
rally covered  all  round  with  a thick,  cartilaginous  coat  of  false 
membrane,  uniting  it  to  the  interior  of  the  thoracic  walls ; and  any 
cavity  formed  in  this  region  is  thus  prevented  from  opening  into 
the  pleura,  and  the  general  cavity.  But  if  in  the  lower  region  of 
the  lower  lobe,  any  large  tubercular  mass  is  softened  and  expelled, 
and  leaves  a considerable  cavity,  verging  towards  the  pectoral  and 
axillary  regions,  it  occasionally  happens  that  adhesion  has  not  taken 
place  there,  and  that  the  walls  of  the  cavity,  already  extenuated  to 
an  extreme  degree,  give  way,  or  are  perforated,  especially  during 
a fit  of  coughing,  air  and  once  tubercular  matter  escape  into  the 
pleural  cavity,  and  there  produce  first  collapse  of  the  lung,  and 
then  pleuritic  inflammation.  Among  112  cases  observed  by  Louis, 
perforation  was  known  to  take  place  in  eight  cases,  and  in  seven  of 
these  it  took  place  on  the  left  side.  Among  100  cases  recorded  in 
the  Royal  Infirmary  Report,  perforation  took  place  in  six,  in  three 
on  the  right  side,  and  in  three  on  the  left.  Since  the  publication 
of  that  report,  I have  met  with  two  cases  of  perforation,  among 
eighteen  cases  inspected  under  my  own  care  ; and  in  one  case,  per- 
foration took  place  in  the  left  side,  in  the  lower  part  of  the  supe- 
rior lobe,  and  another  in  the  middle  lobe  of  the  right  side. 

Morbid  Anatomy  of  the  appendages  of  the  Lungs  and 
THE  OTHER  ORGANS. — Besides  the  state  of  the  lungs  above  de- 
scribed, the  trachea,  larynx,  and  epiglottis  are  liable  to  present 
various  lesions.  The  membrane  of  the  epiglottis  is  always  redden- 
ed, and  sometimes  softened  ; and  the  whole  laryngeal  and  tracheal 
membrane  is  reddened  and  softened,  or  rendered  flaccid.  Ulcers 
also,  various  in  size  and  shape,  may  be  formed  in  these  parts. 


MORBID  STATES  OF  OTHER  ORGANS  IN  CONSUMPTION.  1029 

Among  102  cases  examined  by  Louis,  ulcers  of  the  epiglottis  were 
found  in  eighteen  cases  (one-sixth),  ulcers  of  the  larynx  in  twenty- 
two  cases  (one-fifth),  and  ulcers  of  the  trachea  in  thirty-one  cases 
(one-third). 

Most  of  the  ulcers  of  the  epiglottis  are  confined  to  the  lower  or 
laryngeal  surface  of  that  cartilage.  The  ulcers  are  generally  small, 
one,  two,  or  three  lines  in  diameter.  They  are  more  common  in 
males  than  in  females. 

The  most  frequent  seat  of  ulcers  of  the  larynx  is  the  junction  of 
the  vocal  chords ; then  the  vocal  chords  themselves,  especially  their 
posterior  part;  and  lastly,  the  base  of  the  arytenoid  cartilages ; the 
upper  part  of  the  larynx,  and  the  interior  of  the  ventricles.  In 
some  rare  cases  one  or  more  of  the  vocal  chords  are  denuded  or 
destroyed,  and  the  base  of  the  arytenoid  cartilages  exposed. 

Ulcers  of  the  trachea,  sometimes  very  large,  are  found  chiefly  in 
the  posterior  or  fleshy  part  of  the  canal,  and  are  attended  with  a 
red  colour,  more  or  less  deep,  of  the  contiguous  mucous  membrane, 
and  some  softening  and  thickening.  In  rare  cases,  the  ulceration 
spreads  so  much  as  to  denude  or  destroy  more  or  less  completely 
several  of  the  cartilaginous  rings ; and  in  that  case  the  ulcerated 
ends  of  the  rings  give  the  margins  of  the  ulcer  a peculiar,  irregu- 
lar, and  denticulated  appearance. 

The  only  general  result  that  can  be  established  regarding  the 
heart  is,  that  it  is  rendered  smaller  and  softer  than  usual,  or  is 
atrophied. 

Mr  Abernethy  found  that,  in  severe  cases  of  pulmonary  con- 
sumption, in  which  the  lungs  were  much  occupied  by  tubercular 
masses,  by  injecting  the  arteries  and  veins  of  the  heart,  the  injec- 
tion readily  flowed  into  the  chambers  of  the  organ,  and  that  the 
left  ventricle  was  first  and  most  completely  filled.  He  found  that 
the  channels  of  this  injection  were  the  foramina  ThehesH,  which, 
though  in  the  natural  state  few  and  small,  becomes  numerous  and 
large  in  disease  of  the  lungs,  especially  tubercular  induration, 
which  impedes  the  circulation  of  the  pulmonary  artery,  and  thereby 
distends  and  gorges  the  right  chambers  of  the  heart  Mr  Aber- 
nethy also  found  ih^foramen  ovale  more  or  less  open  in  the  hearts 
of  persons  destroyed  by  pulmonai’y  consumption.* 

In  about  from  one-tenth  to  one-fifth  of  cases  of  consumption,  the 

* OBservations  on  the  Ff/rainina  Thehesii  of  the  Heart.  By  John  Abernethy, 
F .K.S.  Phil.  Trans.  1708.  Part  I.  p.  ID. 


1030 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


stomach  is  enlarged  or  distended  to  two  or  three  times  its  usual 
bulk.  The  mucous  membrane  of  the  organ  is  very  generally  in  an 
unhealthy  state,  either  wholly  or  partially.  It  may  be  in  the  splenic 
end  softer  and  thinner  than  natural,  with  a bluish-white  or  yellow- 
ish colour.  This  takes  place  in  one-fifth. 

The  same  part  may  be  reddened  or  softened.  In  about  one-fifth 
the  mucous  membrane  of  the  anterior  coat  is  red,  thickened,  and 
softened, — generally  in  connection  with  enlargement  of  the  liver. 
Ulcers,  prominences,  and  granulations,  are  found  in  a smaller  pro- 
portion of  cases.  Most  of  these  lesions  are  to  be  viewed  as  the 
effect  of  some  form  of  inflammation  ; and  it  is  established  that,  in 
the  phthisical,  irritation  or  inflammation  of  the  gastric  mucous 
membrane  is  very  readily  induced. 

By  far  the  most  constant  lesion  in  the  alimentary  canal  of  the 
phthisical,  consists  in  some  change  in  the  mucous  membrane  of  the 
ileum  or  of  the  colon. 

The  most  common  lesion  in  the  former  is  the  presence  of  ulcers, 
which  are  observed  in  five-sixths  of  the  cases.  In  one-sixth  they 
occupy  the  whole  tract  of  the  intestine ; and  in  the  other  two-ninths 
they  are  found  only  at  the  lower  part  of  the  ileum.  These  ulcers 
always  correspond  to  the  aggregated  glands  of  Peyer,  in  which  they 
begin ; but  as  the  disease  proceeds,  if  life  be  protracted,  they  ex- 
tend to  the  mucous  membrane  in  general,  and  thus  are  found  to 
occupy  the  greater  part  or  the  whole  circumference  of  the  bowel. 
Their  shape  is  elliptical,  annular,  or  linear.  In  general,  at  the 
commencement,  they  appear  in  one  or  two  points,  that  is,  in  one  or 
two  follicles  of  one  of  the  aggregated  glands.  In  the  advanced 
stage  of  the  disease,  several  of  these  coalescing  may  form  a large 
and  extensive  ulcer.  The  latter  is  mostly  seen  at  the  lower  end  of 
the  ileum,  where  that  bowel  enters  the  colon.  In  some  instances, 
these  ulcers  may  commence  in  the  isolated  follicles  ; but  this  is  not 
common. 

A lesion  less  frequent  is  the  presence  of  granulations,  semicar- 
tilaginous  or  tubercular,  in  the  ileum.  These  lesions,  which  appear 
to  be  seated  in  the  isolated  follicles  of  the  bowel,  and  which  consist 
in  tubercular  degeneration  of  the  follicles,  take  place  in  three- 
eighths  of  the  cases. 

Much  in  the  same  manner,  and  at  the  same  rate,  is  the  mucous 
membrane  of  the  colon  liable  to  be  diseased.  It  is  reddened  either 
continuously  or  in  patches.  The  most  common  lesion  is  the  pre- 


MORBID  STATES  OF  OTHER  ORGANS  IN  CONSUMPTION.  1031 


sence  of  ulcers,  which  are  formed  in  from  eight-elevenths  to  seven- 
ninths,  or  about  nine-twelfths.  They  may  be  large,  middle-sized, 
or  small.  The  most  common  situations  are  the  caecum,  the  ascend- 
ing colon,  the  transverse  arch,  and  the  rectum,  in  the  order  now 
specified.  When  the  caecum  is  affected,  the  ulceration  is  often  ex- 
tensive, being  associated  with  ulcers  or  ulceration  of  the  lower  end 
of  the  ileum,  the  ileo-caecal  valve,  which  is  often  stripped  of  its  mu- 
cous membrane,  or  altogether  destroyed,  and  over  the  whole  inner 
surface  of  the  caecum.  In  the  ascending  colon  and  transverse  arch, 
the  ulcers  present  the  appearance  of  broad  flatfish  patches,  the 
largest  diameter  being  across  the  intestine,  the  converse  of  what  is 
observed  in  the  ileum.  These  ulcers  may  commence  in  the  mucous 
follicles  of  the  colon ; but  they  eventually  pass  to  the  mucous  mem- 
brane in  general. 

Tubercular  granulations  are  found  in  the  colon  in  a smaller 
proportion  of  cases. 

Of  these  ulcers  or  ulcerated  patches  it  is  a pretty  general  result, 
that,  as  they  destroy  the  mucous  membrane,  and  advance  through 
the  subjacent  coats  to  the  peritoneum,  they  cause  in  the  latter  in- 
flammation in  minute  isolated  points  or  spots,  followed  by  eflfusion 
of  albuminous  fluid,  which  coagulates  and  adheres  in  an  equal 
number  of  minute  points,  opaque,  elevated,  and  generally  isolated, 
but  touching  each  other,  so  as  to  form  a rough  patch,  circular  or 
oval  in  shape.  In  this  state,  these  small  whitish  opaque  bodies  pre- 
sent the  appearance  of  tubercular  specks,  and  are  hence  called  by 
many  authors  tubercles  of  the  peritonaeum.  Whatever  be  the  name 
applied  to  them,  they  are  formed  in  the  mode  now  mentioned. 

The  final  cause  of  this  peritoneal  inflammation  is  to  counteract 
ulcerative  perforation,  and  to  thicken  and  strengthen  the  bowel. 
In  some  rare  cases,  however,  this  object  is  defeated,  and  the  ulcer- 
ation destroys  all  the  textures,  and  the  -peritoneum  suddenly  gives 
way,  allowing  the  escape  of  air  and  the  intestinal  contents  into  the 
abdomen,  and  causing  sudden  fatal  peritonitis.  This  accident  is, 
however,  not  very  common.  One  example  only  have  I met  with 
among  nearly  one  hundred  instances  of  fatal  consumption. 

In  other  instances,  effusion  of  sero-purulent  or  purulent  fluid  is 
found  in  the  peritoneum,  and  soft  coagulable  lymph  between  the 
intestinal  folds,  showing  that  it  must  have  been  inflamed  during 
life. 

In  the  bodies  of  the  phthisical  the  liver  is  very  generally  in  a 


1032 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


morbid  state.  The  most  frequent  change  in  this  country  is  that 
of  kirrhosis,  with  more  or  less  enlargement  and  induration,  in  which 
sections  of  the  gland  show  it  to  have  a peculiar  yellow  colour,  with 
a darker  hue  of  the  acini.  This  fakes  place  in  rather  more  than 
one-third  of  the  cases.  The  most  common  change  in  France  ap- 
pears to  be  the  adipescent  transformation  of  the  organ  which  occurs 
in  one-third  of  the  cases.  In  this  the  organ  is  pale,  fawn-coloured, 
more  or  less  tender  and  friable,  chequered  with  red  outside  as 
w'ell  as  within.  The  bulk  of  the  organ  is  always  increased,  some- 
times to  the  amount  of  twice  its  usual  dimensions.  In  this  coun- 
try, this  change  does  not  take  place  in  so  many  as  one-sixth  of  the 
cases.  The  former  lesion  is  most  common  among  males ; the  lat- 
ter among  females. 

The  brain  is  very  generally  slightly  softer  than  natural.  The 
membranes  are  injected ; and  fluid  is  effused  beneath  the  arachnoid 
membrane  and  within  the  ventricles. 

Tubercular  deposits  or  tyromatous  matter,  fluid  or  semifluid,  or 
solid,  are  found  in  various  other  organs  besides  the  lungs.  Thus 
the  ileum  and  the  colon  are  said  to  become  the  seat  of  this  deposit ; 
but  perhaps  it  is  rather  the  albuminous  effusion  in  the  granular 
shape,  than  real  tyromatous  matter,  which  has  received  this  cha- 
racter. The  deposit,  however,  is  found  in  the  mesenteric  glands, 
the  cervical  lymphatic  glands,  the  lumbar  glands,  the  prostate,  the 
spleen,  ovaries,  kidneys,  womb,  brain,  and  cerebellum.^  in  the  order 
now  mentioned. 

The  usual  termination  of  the  lesions  of  the  lungs  above  described 
is  in  death.  As  the  contents  of  the  tubercular  masses  are  softened 
and  expelled  into  the  bronchial  tubes,  they  cause  in  these  and  in 
the  windpipe  and  lungs  most  violent  irritation  and  inflammation, 
with  consequent  copious  secretion  of  puriform  mucus,  which  is 
mingled  and  spit  up  with  the  proper  tubercular  matter.  As  this 
process  advances  with  several  tubercular  masses  simultaneously  and 
successively,  very  general  bronchitic  and  tracheal  inflammation  is 
induced ; and  at  the  same  time  with  them  symptoms  of  peripneu- 
mony  and  pleurisy  may  be  combined  from  the  causes  already  spe- 
cified. In  this  state  of  matters,  the  function  of  respiration  is 
gradually  confined  in  its  extent  and  effect,  until  it  is  nearly  anni- 
hilated, when  perhaps  not  more  than  one-fourth,  or,  in  some  cases, 
one-sixth,  or  one-tenth  of  the  lungs  is  left  permeable  to  air  and 

blood.  Death  then  ensues,  partly  as  the  effect  of  the  exhaustion 

4 


MORBID  STATES  OF  TEE  LUNGS  IN  CONSUMPTION. 


1033 


from  constant  tracheo-bronchial  irritation,  partly  as  the  effect  of 
exhaustion  from  annihilated  respiration. 

Notwithstanding  the  frequency  of  this  as  the  usual  termination 
of  the  process  of  tubercular  destruction,  softening,  and  excavation, 
there  is  reason  to  believe  that,  in  an  extremely  small  proportion  of 
cases,  recoveries  from  very  ominous  states  take  place  after  all  the 
usual  signs  of  consumption  have  existed  for  a sufficient  time  to 
render  the  conclusion  probable  that  these  symptoms  were  caused 
by  tubercular  softening  and  excavation.  As  the  evidence  of  this 
fact  is  at  once  doubtful  and  important,  it  is  best  to  state  it,  as  it 
most  usually  is  observed. 

1.  It  occasionally  happens,  that,  in  inspecting  the  bodies  of  per- 
sons destroyed  by  several  different  diseases,  there  is  observed  in  the 
upper  lobe  of  the  lungs  a peculiar  morbid  state.  The  pleura  is 
puckered  and  shrivelled  into  small,  firm,  irregular  portions,  in 
which  there  is  distinctly  felt  a sort  of  leathery  firmness,  and  beneath 
that  a spot  or  body  or  round  globular,  pretty  firm  and  resisting. 
When  this  is  divided,  the  pleura  is  found  to  be  shrivelled  and  a 
little  indurated,  contracted  downwards  and  inwards  upon  the  hard 
body,  and  the  substance  of  the  lung  hardened  and  shrinking,  en- 
closing the  hard  body,  which  is  then  found  either  like  a portion  of 
soft  putty,  or  more  consistent  like  chalk,  slightly  moistened  with 
water.  This  is  regarded  as  a cicatrized  or  contracted  vomica. 
The  putty-like  or  chalky  contents  are  the  thicker  part  of  the  soft- 
ened matter  of  the  tubercle  after  the  thinner  have  been  expecto- 
rated or  removed  by  absorption.  In  cases  of  this  kind,  in  which 
such  chalk-like  masses  usually  encysted,  are  contained  in  the  apex 
or  upper  regions  of  the  upper  lobes,  the  rest  of  the  lungs  are  in 
general  either  free  from  tubercular  masses,  or  are  little  occupied 
by  them,  or  present  some  miliary  tubercles  disseminated  through 
their  substance. 

In  some  instances,  these  solid  bodies  are  perfectly  firm  and 
almost  stony,  grating  against  the  knife. 

Changes  of  this  kind,  howevei’,  M.  Louis  thinks,  do  not  depend 
on  any  determinate  lesion.  From  the  soundness  of  the  rest  of  the 
lung,  and  the  small  space  which  such  bodies  occupy,  it  is  possible 
that  these  putty-like  bodies  may  be  tyromatous  masses  in  the  early 
stage  degenerated,  and  the  calcareous  concretions,  phlebolites,  or 
concretions  in  parts  of  the  lungs  previously  inflamed. 

2.  In  other  instances,  however,  appearances  of  a less  equivocal 
nature  are  recognized.  In  examining  the  bodies  of  persons  who 


1034 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


have  previously  suffered  from  cough,  breathlessness,  expectoration, 
and  wasting,  there  are  found  in  the  upper  lobe  of  the  lungs,  irre- 
gular cavities  lined  by  a semicartilaginous  membrane,  similar  to 
that  formerly  described,  but  firmer  and  smoother,  containing 
particles  of  whitish  chalky-like  matter,  or  even  putty-like  matter 
adhering.  In  other  instances,  cavities  irregular  in  shape,  but 
marked  by  septa  or  partitions,  are  found  lined  by  a firm  smooth 
false  membrane,  empty,  that  is  containing  only  air ; while  in  the 
same  lung  may  be  found  tubercular  masses  partially  or  wholly 
softened,  and  in  some  instances,  crude  tubercular  masses. 

At  the  near  extremity  of  such  cavities  the  bronchial  tubes,  which 
are  truncated,  are  in  general  also  dilated  or  enlarged  in  diameter ; 
white  those  at  the  further  extremity  are  shrunk  and  contracted,  or 
altogether  impermeable.  These  cavities  also  themselves  show  a 
tendency  to  contraction  by  the  lung,  and  even  the  thoracic  parietes 
pressing  them  mutually  together.  When  this  contraction  or 
shrinking  of  the  cavities  takes  place,  the  extremities  of  the  nearer 
bronchial  tubes  also  are  contracted,  from  participating  in  the  cen- 
tripetal pressure;  and,  in  some  instances,  they  are  impermeable 
and  obliterated.  This  lesion  has  been  well  represented  by  Rey- 
naud  in  his  fourth  plate,  fig.  1,  who  has  detailed  several  cases, 
showing  the  frequency  of  obliteration  of  the  tubes,  in  cases  both  of 
fiital  phthisis,  and  in  those  in  which  partial  recovery  appeared  to 
take  place. 

Lastly^  In  some  instances  in  the  apex  of  the  lungs  are  found 
simply  masses,  fibrous  and  cellulo-fibrous,  with  firm  cartilaginous 
intersections  without  cavity,  and  without  permeable  bronchial  tubes. 

From  these  several  facts  it  is  inferred,  that  the  cavities  now 
mentioned  are  tubercular  cavities  emptied  and  partially  or  wholly 
cicatrized ; and  2rf,  that  the  solid  firm  portions  are  cavities  in 
which  great  or  complete  contraction  had  taken  place, 

§ 1 1.  Kirrhosis. — This  name  Dr  Corrigan  applies  to  the  following 
condition  of  the  lung.  The  substance  of  the  lung  is  firm  and  solid 
to  touch,  and  void  of  crepitation  ; it  is  of  grayish-red  colour  and 
tough  ; when  divided,  it  is  traversed,  in  all  directions,  by  thick  white 
bands  of  fibro-celiular  tissue.  The  bronchial  tubes,  instead  of 
growing  smaller  in  diameter  as  they  proceed  to  their  terminations, 
increase  in  size  and  capacity,  until  they  terminate  in  oval  or  round- 
ed cavities,  in  some  of  which  are  seen  crowded  together  the  open- 
ings of  the  small  bronchia,  giving  them  an  appearance  similar  to 
that  of  the  bronchia  of  the  tortoise.  The  lining  membrane  of  the 


KIKRHOSIS  OF  THE  LUNG. 


1035 


large  dilated  bronchia  is  red  and  thickened.  The  small  bronchia 
are  not  permeable  beyond  their  orifices.  The  tubes  are  generally 
filled  with  viscid  puriforra  mucus.  The  lung  itself  is  generally 
smaller  than  natural  or  contracted.  No  tubercles  are  observed. 
But  it  is  common  to  find  the  pleura  covered  with  lymph,  or  adher- 
ing to  the  costal  pleura. 

These  changes  Dr  Corrigan  ascribes  to  the  previous  existence 
of  chronic  inflammation  in  the  filamento-cellular  tissue  of  the  lung, 
converting  it  into  a fibro-cellular  structure,  which  contracts  toward 
the  centre  of  the  organ,  and  in  its  contraction  draws  along  with  it 
the  elastic  substance  of  the  lung,  in  the  same  manner  as  the  cellular 
tissue  of  the  liver  is  supposed  to  contract  that  organ.* 

This  explanation  is  hypothetical.  The  lesion  has  been  described 
and  represented  by  Andral,  Reynaud,  and  Dr  Carsewell  as  hyper- 
trophy and  dilatation  of  the  bronchial  tubes.  These  are  manifestly 
both  dilated  and  their  walls  are  thickened  and  h3rpertrophied,  while 
their  cellular  or  vesicular  terminations  are  obliterated.  These  are 
facts.  All  the  rest  are  opinions.  All  that  can  be  said  of  this 
change  is,  that  it  seems  to  be  the  result  of  an  inflammatory  condi- 
tion of  the  bronchial  tubes,  with  obliteration  of  their  extremities, 
sometimes  with  pleuritic  exudation. 

It  seems  impossible  to  establish  any  analogy  between  this  mor- 
bid state  of  the  lung  and  kirrhosis  of  the  liver.  In  the  latter  dis- 
ease, the  acini  or  granular  elements  are  hypertrophied,  and  they 
contain  bile  or  the  matter  of  bile,  (taurine),  and  colouring  matter, 
and  crystalline  fatty  matter.  Nothing  analogous  to  this  is  seen  in 
the  lung  with  hypertrophied  bronchial  tubes. 

§ 12.  Concretions. — Hard  gritty  or  stony  bodies  are  very  fre- 
quently found  in  the  substance  of  the  lungs,  f The  most  usual  situation 
for  these  bodies  is  at  the  apex  of  one  or  both  lungs,  or  somewhere 
in  the  upper  part  of  the  upper  lobe.  In  some  cases  the  pleura  ad- 
heres to  the  costal  pleura  over  the  site  of  these  bodies,  so  that  they 
are  not  recognized  until  the  lung  is  removed  from  the  chest.  If 
the  pleura  do  not  adhere,  it  is  observed  that  a shrivelled  contracted 
appearance  of  the  spot  with  some  depression  has  taken  place,  as  if 
it  were  the  mark  of  a cicatrix  or  healed  scar  of  the  lung,  while  the 

* On  Cin-hosis  of  the  Lung.  By  D.  J.  Corrigan,  M.  D.  &c.  Dublin  Journal  of  the 
Medical  Sciences,  Vol.  xiii.  p.  206.  Dublin,  1838. 

t A Case  of  Obstructed  Deglutition  from  a preternatural  dilatation  of,  and  bag 
formed  in,  the  Pharynx.  By  Mr  Ludlow,  Surgeon,  Bristol.  Medical  Observations  and 
Inquiries,  Vol.  iii.  London,  1769,  p.  98. 


1036 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


substance  of  the  lung,  to  the  extent  of  one-third  or  half  of  a cu- 
bical inch  is  indurated.  When  this  is  divided,  the  centre  of  the 
mass  is  found  to  consist  of  a whitish-gray  or  bluish  matter,  very 
hard,  and  distinctly  gritty,  or  with  gritty  particles  disseminated 
through  the  mass.  These  bodies  have  been  regarded  by  Laennec 
as  the  remains  or  vestiges  of  cicatrized  vomicce.  It  is  possible  that 
this  may  be  the  case.  But  it  is  to  he  ohs(;rved  that  these  concre- 
tions occur  in  lungs  in  which  there  are  no  tubercles  and  no  vomica: 
or  traces  of  these  cavities  elsewhere. 

Hard  stony  bodies  may  occur  also  in  other  parts  of  the  lungs. 
These  are  variable  in  size,  from  the  bulk  of  a millet  seed  to  that  of 
a bean.  They  are  traced  to  blood-vessels,  and  are  vein  stones ; 
(jilileholitha). 

§ 13.  Parasitical  Animals. — a.  Hydatids. — The  acephalocyst 
has  been  found  in  the  lungs  by  many  observers  ; and  in  several  in- 
stances, acepbalocysts  have  been  discharged  by  coughing.  They 
are  formed  either  in  the  filamento-cellular  tissue,  or  in  the  fhura  ; 
from  either  of  which  they  may  find  their  way  into  the  bronchi  by 
suppuration,  and  hence  be  discharged  by  coughing.  Instances  of 
this  kind  are  not  uncommon.* 

On  the  origin  and  pathological  relation  of  these  bodies,  a new, 
and,  in  several  respects,  peculiar  view  has  been  given  by  M.  C. 
Baron,  who,  from  the  phenomena  of  various  cases,  traces  an  inti- 
mate connection  between  hemorrhagic  effusions,  and  the  presence 
of  acephalocysts.  This  author  thinks,  that  when  blood  is  effused 
into  the  pulmonic  substance,  the  mass  undergoes  various  changes, 
the  central  continuing  red,  the  peripheral  yellow.  The  central 
portion  may  be  expelled  through  orifices  formed  in  the  peripheral ; 
or  it  is  partly  absorbed  by  the  peripheral  portion ; which  is  thus 
progressively  transformed  into  a cyst,  which  after  some  time  may 
become  a hydatid.f 

This  method  of  explanation  seems  more  applicable  to  the  origin 

* Case  of  Hydatids  discliarged  by  Coughing.  Related  in  a Letter  from  Jolm 
Collett,  M.D.,  Newbury,  Berkshire.  Transactions  of  College  of  Physicians,  Vol.  ii.  p. 
486.  Lond.  1772.  135  acephalocysts  coughed  up  in  the  course  of  116  days. 

Case  of  Hydatids  coughed  up  from  the  Lungs.  By  Dr  Doubleday  of  Hexham. 
Medical  Observations  and  Inquiries,  Vol.  v.  p.  143.  Lond.  1776. 

Hydatids  in  the  Air  Tubes  of  the  Lungs.  In  a Letter  from  a Physician  in  London 
(Dr  Pearson).  Edinburgh  Med.  and  Surg.  Journal,  Vol.  vii.  p.  490.  Edin.  1811. 

Case  of  Hydatids  discharged  from  the  Lungs.  Guy’s  Hospital  Reports,  Vol.  i. 
p.  507.  Lond.  1836. 

t De  la  Nature  et  du  Developpement  des  Produits  Accidentels.  Par  M.  Le  Doc- 
teur  Ch.  Baron.  Memoires  de  I’Academie,  Tome  .\i.  p.  381.  Paris,  1845. 


■\VORJIS. — ENKEPHALO:\IA  OF  THE  LUNGS. 


1037 


of  serous  cysts  than  that  of  acephalocysts.  The  author  neverthe- 
less maintains  its  validity,  because  hydatids  are  found  in  the 
blood,  and  their  ova  may  therefore  he  effused  with  it.  To  this  it 
may  be  answered,  that,  admitting  that  hydatids  or  their  germs 
exist  in  the  blood,  it  must  be  easy  for  them  to  find  their  way  into 
the  lungs  without  the  effusion  of  blood. 

Hydatids,  when  existing  in  the  lungs,  either  cause  suppuration 
and  then  expulsion  with  more  or  less  disorder,  general  and  local ; 
or  they  may  die  ; the  cysts  contract  and  become  opake ; and  they 
then  form  a sort  of  lamellated  tumour,  the  presence  of  which  does 
not  appear  to  be  detrimental. 

b.  Worms. — Instances  are  recorded  by  several  authors,  among 
others  Schenke,  of  worms  having  been  discharged  from  the  lungs. 
It  has  been  generally  believed — that  these  cases  were  the  result  of 
the  credulity  of  the  recorders ; and  so  perhaps  some  of  them  may. 
The  same  objection,  however,  can  scarcely  be  urged  against  a case 
recorded  by  Dr  Thomas  Percival,  who  mentions  that  a patient, 
aged  49,  after  cough  and  oppression  at  the  breast,  expelled 
by  coughing,  in  February  1774,  two  masses,  the  largest  the 
size  of  a nutmeg,  of  a chocolate  colour,  upon  dividing  which  it 
was  found  to  contain  a number  of  worms  like  maggots.  The  cough 
and  expectoration  diminished  in  severity ; but  the  result  as  to  final 
recovery  is  not  stated.* 

§ 14.  Heterologous  Growths. — Both  skirrhus  and  enkepha- 
loma  have  been  represented  to  be  found  in  the  lungs.  As  to  the 
latter  there  is  no  doubt.  The  occurrence  of  the  former  is  more  ques- 
tionable. 

Bayle  was  the  first  who  in  1810  directed  attention  to  the  precise 
character  of  cancer  in  the  lungs.  He  gives  three  cases ; in  the  first 
of  which  the  cancerous  masses  were  hard,  and  presented  the  white 
shining  appearance  of  fresh  bacon  or  lard.  In  the  other  two  the 
tumours  bore  the  characters  of  brain  or  genuine  enkephaloma. 
These  were  instances  of  enkephaloid  disease  affecting  the  lungs. 

Laennec  was  decidedly  of  opinion  that  the  structure  named 
Skirrhus  does  not  take  place  in  the  lung,  and  that  the  only  species 
of  Cancer  found  in  these  organs  is  the  medullary  sarkoma,  or 
enkephaloid  deposit ; and  if  careful  attention  be  given  to  the  cases 
which  were  published  both  before  and  since  his  time,  we  shall  see 
reason  to  admit,  that  this  inference  is  well  founded. 

* Philosophical,  Medical,  and  Experimental  Essays.  By  Thomas  Percival,  M.  D. 
Vol.  iii.  Lond.  1778. 


1038 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


The  cases  of  enkephaloid  disease  published  in  1817  and  1818  by 
Mr  LangstafF showed,  so  far  as  negative  evidence  goes,  that  skirrhus 
does  not  affect  internal  organs ; and  that  enkephaloma  is  the  usual 
form  in  which  malignant  disease  attacks  the  lungs.  With  the  ex- 
ception of  one  case  referred  to  the  head  of  tuberculated  sarkoma, 
all  presented  the  usual  characters  of  enkephaloma ; and  probably 
this  was  enkephaloid  deposit  in  the  tuberculated  form.* 

These  facts  and  considerations  deducible  from  them,  have  led 
Mr  Travers  to  consider  skirrhus  and  enkephaloma  as  dependent  on 
the  same  generating  cause,  and  that  this,  whatever  it  be,  produces 
in  one  order  of  organs,  mostly  external,  the  skirrhus  deposit,  and 
in  another  order,  mostly  internal,  the  enkephaloid  formation. f It 
is  not  easy  to  say  whether  this  view  be  the  correct  one  or  not ; but 
the  facts  which  support  it,  show  the  truth  of  the  doctrine  which  has 
been  several  times  stated  in  the  course  of  this  volume,  that  enkepha- 
loma is  the  most  common  malignant  deposit  that  affects  internal 
organs. 

It  seems  indeed  doubtful  whether  genuine  skirrhus  has  been  found 
in  the  lungs ; for  all  the  authentic  cases  hitherto  recorded  present 
the  characters  of  the  enkephaloid  deposit.^  It  has  been  observed  to 
pass  from  the  mamma  to  the  pleura,  and  thence  to  the  lungs. 
This,  however,  is  not  the  primary  affection  of  the  lungs  by  skirrhus. 

Enkephaloma  is  greatly  more  common,  and,  according  to  the 
most  authentic  evidence  hitherto  adduced,  must  be  regarded  as  the 
principal  form  in  which  cancer  affects  the  lungs.  It  may  appear 
in  four  different  modes. 

In  the  first  place,  the  enkephaloid  matter  is  deposited  in  the  bron- 
chial glands,  and  causes  the  gradual  enlargement  of  these  bodies 
and  their  encroachment  on  the  bronchial  tubes,  and  the  substance  of 
the  lungs.  As  this  enlargement  proceeds,  the  breathing  is  increased 
in  difficulty,  and  fluid  is  effused  within  the  pleurce.  The  masses 

■*  Cases  of  Fungus  Haematodes  with  Observations,  &c.  By  George  LangstafF,  Esq., 
&c.  Medico-Chirurgical  Transactions,  Vol.  viii.  p.  272,  &c.  London,  1817. 

Cases  of  Fungus  Haematodes,  Cancer,  and  Tuberculated  Sarkoma,  &c.  By  George 
LangstafF,  Esq.  Medico-Chirurgical  Transactions,  Vol.  ix.  p.  297.  London,  1818. 

t Observations  on  Local  Diseases  termed  Malignant.  By  Benjamin  Travers, 
F.R.S.,  &c.  Parts  I.  and  II.  Medico-Chirurgical  Transactions,  vol.  xv.  p.  195  and 
228.  Lond.  1829.  Part  III.  Vol.  xvii.  p.  300.  London,  1832. 

i Case  of  Extensive  Carcinoma  of  the  Lungs.  By  George  Burrows,  M.  D.,  &c. 
Medico-Chirurgical  Transactions,  Vol.  xxvii.  p.  118.  Lond.  1844. 

Cases  of  Malignant  Disease  of  the  Lungs.  By  H.  Marshall  Hughes,  M.  D.  Guy’s 
Hospital  Reports,  Vol.  vi.  p.  330.  Lond.  1842. 


ENKEPHALOMA  OF  THE  LUNGS. 


1039 


vary  in  size  according  to  the  duration  of  the  disease,  from  the  bulk 
of  a gooseberry  or  a filbert  to  that  of  small  pippins.  IMost  com- 
monly several  masses  are  found  united  in  one  irregular  tumour;  or 
they  form  a chain  of  tumours  extending  through  the  posterior  me- 
diastinum along  the  bronchial  tubes.  They  are  gray  or  gray-white, 
moderately  firm,  and  present  the  usual  characters  of  enkephaloma. 

The  presence  of  these  bodies  produces  a peculiar  form  of  breath- 
lessness with  orthopnoea ; at  first  recurring  in  fits,  afterwards  con- 
stant, and  causing  a hissing,  wheezing,  roaring  noise  over  the  site 
of  the  bronchial  tubes,  with  crowing  inspiration. 

In  the  second  form,  the  disease  affects  the  lungs  in  the  chest, 
commencing  either  in  the  pleura,  or  in  the  substance  of  the  lungs. 
The  enkephaloid  deposit  may  appear  either  in  the  encysted  or  the 
unencysted  form.  But  in  whichever  way  it  appears,  it  rapidly  oc- 
cupies the  whole  interior  of  the  chest,  pushing  the  lung  away  from 
the  ribs  towards  the  mediastinum.  After  some  time  it  occupies  the 
whole  of  the  interior  of  the  chest  with  one  continuous,  yet  lobulated 
mass  of  enkephaloid  deposit.  The  presence  of  this  may  be  known 
during  life  by  the  complete  dulness  emitted  by  the  chest  on  per- 
cussion, and  the  total  absence  of  respiratory  murmur,  with  great 
breathlessness  and  debility. 

After  death,  which  follows  quickly,  the  demithnrax  is  found  oc- 
cupied with  this  enkephaloid  mass,  and  the  lung  compressed  into  a 
very  small  space  at  the  upper  part  of  the  thorax  and  the  mediastinum, 
is  scarcely  to  be  recognized.  The  tumour  presents  the  usual  charac- 
ters of  enkephaloma.  Some  parts  are  soft,  pulpy,  and  semifluid, 
like  brain,  or  tbe  brain  of  the  foetus ; others  are  firm  and  consist- 
ent like  cream-cheese  ; others  are  a mixture  of  soft  gray-coloured 
cerebriform  matter  with  blood  and  blood-vessels. 

In  the  third  mode  of  approach,  the  enkephaloid  matter  appears 
first  in  the  liver,  and  after  occupying  the  greater  part  of  that  gland, 
it  proceeds  to  affect  the  diaphragmatic  peritoneum,  the  diaphragm 
itself,  the  pleura^  and  the  lower  lobe  of  the  right  lung.  Through 
this  the  enkephaloid  deposit  extends  gradually  until  it  occupies  the 
middle  lobe  and  the  lower  part  of  the  upper  lobe.  In  this  case  it 
is  not  easy  to  say  whether  the  tumour  displaces  the  lung,  or  the 
enkephaloid  matter  is  infiltrated  into  the  pulmonary  substance,  as  it 
is  in  that  of  the  liver.  In  the  instances  in  which  I have  observed  this 
mode  of  occupation,  the  new  growth  seemed  to  advance  by  suc- 
cessive steps  from  one  texture  to  another,  and  the  lungs  appeared 
to  be  occupied  from  their  proximity  to  the  organs  first  attacked. 


1040 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


In  this  mode  of  approach,  the  new  growth  passes  to  the  left  side 
of  the  diaphragm,  the  tendinous  centre,  the  pericardium,  heart,  and 
part  of  the  left  lung.  The  extent  to  which  the  growth  proceeds  in 
this  direction  is  a mere  question  of  time.  If  life  he  sufficiently 
prolonged,  the  growth  is  found  affecting  a considerable  portion  of 
the  left  lung.  If  the  patient  be  destroyed  early,  then  less  of  that 
lung  is  involved. 

It  must  further  be  allowed  that  enkephaloma  appears  to  be  de- 
posited in  the  form  of  tuberous  masses  in  the  lungs,  much  in  the 
same  manner  in  which  they  are  deposited  in  the  liver.  Such  was 
the  mode  of  deposition  in  the  cases  given  by  Mr  Langstaff  and  Mr 
Lawrence.  The  tuberosities  are  further  stated  to  have  been  en- 
closed within  very  delicate  cysts.  Some  of  these  were  very  vascu- 
lar. In  one  case  given  by  Mr  Langstaff,  the  deposit  had  affected 
the  uterus  and  lungs,  but  not  the  liver  or  other  abdominal  viscera. 
These  masses  vary  in  size  from  the  bulk  of  peas  to  that  of  small 
apples.* 

When  the  disease  appears  in  the  left  demithornx,  it  by  its  increas- 
ing size,  not  only  displaces  the  lung  to  the  mediastinum  and  upper 
part  of  the  chest,  but  it  thrusts  the  heart  over  towards  the  right 
side  of  the  chest.f 

Dr  Warren  records  the  case  of  a man  of  25  in  whom  colloid 
cancer  affected  the  subcutaneous  cellular  tissue,  the  absorbent 
glands,  the  skull,  the  muscles,  the  heart,  the  lungs,  the  liver,  pan- 
creas, and  kidneys.'^:  Other  instances,  however,  would  be  required 

to  confirm  the  inference  that  colloid  cancer  affects  the  lungs. 

§ 15.  Melanosis, — Of  this  deposit  two  forms  are  observed  to 
take  place  in  the  lungs ; one  true  melanosis ; the  other  consisting 
of  a deposition  or  formation  of  carbonaceous  matter  from  smoke 
and  small  dust  inhaled,  and  which  has  been  distinguished  by  the 
name  spurious  melanosis.  Between  these  affections,  however,  though 
similar,  there  is  no  natural  alliance. 

In  true  melanosis  the  deposit  takes  place  in  two  modes.  In  one 
it  affects  first  the  bronchial  glands,  infiltrating  them  with  a dark- 
blue-coloured  matter,  most  commonly  solid,  sometimes  slightly 
fluid,  semi-fluid,  or  pasty.  The  glands  are  at  the  same  time  en- 
larged, and  usually  increase  in  size  as  the  deposit  proceeds ; and 

* Cases  of  Fungus  Haematodes,  &c.  By  George  Langstaff,  Esq.  Medico-Chinrrg- 
Transactions,  Vol.  viii.  and  ix. 

t On  Malignant  Tumours  connected  with  the  Heart  and  Lungs.  By  John  Sims,  ■ 
M.  D.,  &c.  Medico-Chirurgical  Transactions,  Vol.  xviii.  p.  281.  London,  1833. 

+ Peculiar  Case  of  Gelatiniform  Cancer,  &c.  with  the  Appearances  on  Dissection. 
By  John  C.  Warren,  M.  D.  Med.-Chirurg.  Trans.  Vol.  xxvii.  p.  385.  London,  1 844. 


MORBID  STATES  OF  THE  LUNGS — SPINOUS  MELANOSIS.  1041 


thus  encroach  on  the  lung.  In  the  other  mode,  the  melanotic  mat- 
ter is  either  infiltrated  into  the  substance  of  the  pulmonic  filamento- 
cellular  tissue,  or  it  is  deposited  in  cysts  contained  or  formed  within 
the  same.  Of  this,  instances  are  given  by  various  authors,  among 
others,  by  Mr  Langstaflr. 

The  melanotic  deposit  is  liable  to  occur  in  conjunction  with  the 
enkephaloid.  In  the  first  variety  of  the  second  case,  the  melano- 
tic matter  appears  in  the  form  of  black  or  blue  specks,  patches,  or 
lines  and  streaks  disseminated  through  the  pulmonic  parenchyma. 
In  this  instance,  they  are  probably  in  the  interlobular  filamento- 
cellular  tissue. 

In  spurious  melanosis,  the  black  matter  is  diffused  pretty  regu- 
larly through  the  whole  lung.  The  expectoration  is  always  more 
or  less  black ; and  the  bronchial  tubes  are  filled  with  hlack  or  dark- 
blue  puriform  mucus.  The  bronchial  membrane  is  tinged  of  a 
dark  colour ; and  the  substance  of  the  lung  is  more  or  less  exten- 
sively black  ; while  it  is  often  occupied  with  blue  or  black  indurated 
patches  and  masses,  and  not  unusually  with  tubercular  masses  and 
vomicae.  From  a lung  in  this  state,  a large  quantity  of  black-co- 
loured fluid  may  be  expressed. 

The  cause  of  the  blackening  in  spurious  melanosis  or  the  coal- 
miners’ lung  is  various.  In  one  set  of  cases,  the  black  matter  has 
been  found  to  be  coal  in  a state  of  very  minute  division,  most  pro- 
bably mechanical.  In  another  set  of  cases,  it  has  been  represented 
to  be  carbonaceous  matter  inhaled  from  the  smoke  of  the  lamps 
and  candles  used  by  the  miners.  In  a third  set,  again,  it  has  been 
maintained,  that  it  is  the  carbonaceous  matter  inhaled  after  explo- 
sions of  the  adjoining  strata  by  means  of  gunpowder.  For  farther 
information  on  all  these  points,  I refer  to  the  papers  by  Dr  James 
Gregory,*  Mr  Graham,f  Dr  William  Thomson, Dr  Hamilton, 
and  Dr  Stratton  ;§  and  a memoir  by  M.  Natalis  Guillot.|| 

* Case  of  peculiar  Black  Infiltration  of  the  whole  Lungs  resembling  Melanosis.  By 
James  C.  Gregory,  M.  D.  Edin.  Med.  & Surg.  Journ.  Vol.  xxxvi.  p.  389.  Edin.  1831. 

+ On  the  Existence  of  Charcoal  in  the  Lungs.  By  Thomas  Graham,  E.  R.  S.  E., 
&c.  Edinburgh  Medical  and  Surgical  Journal,  Vol.  xhi.  p.  323.  Edinburgh,  1834. 

Cases  by  G.  Hamilton,  M.  D.  &c.  Case  2d.  Edinburgh  Medical  and  Surgical  Jour- 
nal, Vol.  xlii.  p.  297.  Edinburgh,  1834. 

On  Black  Expectoration  and  the  Deposition  of  Black  Matter  in  the  Lungs,  par- 
ticularly as  occurring  in  Coal-miners,  &c.  By  William  Thomson,  M.  D.  Med.-Chir. 
Trans.  Part  I.  Vol.xx.  p.  230.  Lond.  1837  ; and  Part  II.  Vol.  xxi.  p.  340.  Lond.  1838. 

§ Case  of  Anthracosis  or  Black  Infiltration  of  the  whole  Lungs.  By  Thomas  Strat- 
ton, M.  D.  Edin.  Med.  and  Siu-g.  Journal,  VoL  xhx.  p.  490.  Edinburgh,  1838. 

II  Archives  Generales,  T.  Ixvii.  p.  1.  Paris,  1845. 

3 u 


1042 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


I merely  observe  that  the  general  conclusion,  which  results 
from  the  history  of  all  the  cases  recorded  and  their  phenomena,  as 
also  from  those  which  have  fallen  under  my  own  observation,  is, 
that,  though  black  infiltration  observed  in  coal-miners  may  exist 
without  disease,  or  with  little  disease  of  the  lungs,  yet  most  com- 
monly it  is  associated  with  very  considerable  disease  both  of  the 
bronchial  membrane  and  lungs.  The  former  is  almost  constantly 
in  a state  of  chronic  inflammation.  In  the  latter  there  are  often 
tubercles,  vomicae,  or  indurated  portions,  sometimes  stony  concre- 
tions. The  lungs  are  also  emphysematous.  The  pleura  is  often 
adherent  over  the  apex,  sometimes  all  over.  The  coal  dust  is  in- 
haled by  all  coal-miners,  and  is  stated  to  be  freely  spit  up  daily  and 
from  time  to  time  without  inconvenience  or  injury.  When,  however, 
the  bronchial  membrane  becomes  inflamed,  either  from  exposure  to 
cold  or  the  inhalation  of  stony  particles,  or  in  working  at  stony 
strata,  then  the  evil  becomes  urgent.  The  lungs  are  often  occupied 
by  tubercles;  and  the  diseased  state  of  these  and  the  bronchial 
membrane  aggravates  into  most  deleterious  effects  the  inhalation 
of  cai’bonaceous  matter,  which  seems  not  to  be  of  itself  very  detri- 
mental, unless  it  has  been  continued  for  a long  time. 


CHAPTER  II. 

The  Heart. 

Section  I. 

Structure  of  the  Heart. 

The  heart  is  a complex  organ  consisting  of  muscular  fibres,  ar- 
ranged so  as  to  form  its  different  chambers,  covered  externally  by 
■pericardium,  and  lined  internally  by  a very  delicate  transparent 
membrane  to  which  the  name  endocardium  is  given.  The  latter  is 
the  only  element  requiring  notice  here. 

The  endocardium  is  a very  thin  transparent  membrane,  which 
resembles  much  the  inner  membrane  of  the  arteries,  and  which  is 
composed,  according  to  Henle,  of  four  separate  tunics.  Its  free 
surface  is  perfectly  smooth,  and  is  formed  by  a sort  of  epithelium, 
which  is  in  immediate  continuation  with  the  epithelium  of  the  ves- 
sels ; that  of  the  right  chambers  with  the  venous  epithelium  ; that 
of  the  left  with  the  pulmonary-venous  and  aortic  epithelium.  Next 
to  this  free  or  epithelial  membrane  is  a layer  of  delicate  and  greatly 


MOKBID  STATES  OF  THE  HEART. — ABSCESS. 


J043 


contorted  fibres,  similar  to  those  which  form  the  striated  membrane 
of  the  vessels.  Then  is  a layer  of  elastic  fibres,  which  may  be  re- 
garded as  an  elastic  tissue.  Lastly,  is  a tissue  which  is  called  by 
Henle  ligamentous,  but  which  is  manifestly  the  filamentous  tissue 
that  unites  it  to  the  muscular  fibres  of  the  heart. 

Of  these  four  tunics,  the  three  first  only  are  proper  to  the  endo- 
cardium. The  fourth  is  common  to  it  and  the  muscular  fibres  of  the 
heart. 

This  description  applies  most  to  the  endocardium  of  the  auricles. 

Within  the  ventricles,  the  endocardium  is  altogether  more  deli- 
cate than  in  the  auricles ; the  striated  tunic  is  thinner ; and  the 
strong  elastic  fibres  are  entirely  wanting. 

The  tricuspid  and  mitral  valves  are  formed  by  duplications  of 
this  membrane ; and  in  them  the  elastic  tissue  is  abundant. 

Section  II. 

Morbid  States  of  the  Heart. 

The  heart  is  liable  to  manifold  lesions,  which  it  would  require  a 
considerable  space  to  describe  with  the  requisite  detail  and  accuracy. 
Several  of  these  have  already  received  consideration,  for  instance 
inflammation  and  various  lesions  of  the  substance  of  the  heart,  un- 
der the  head  of  diseases  of  the  muscular  system,  and  pericarditis 
under  that  of  diseases  of  the  serous  membranes.  The  most  im- 
portant which  deserve  consideration  here  are  inflammation  of  the 
lining  membrane,  (endocarditis),  and  its  effects,  induration  or  ossi- 
fication of  the  valves ; hypertrophy,  partial  or  general ; atrophy  ; and 
passive  aneurism. 

§ 1.  Abscess  of  the  heart. — This  has  been  already  considered 
at  some  length.  Besides  the  cases  there  mentioned,  I may  notice 
the  following  as  not  less  conclusive.  Dr  Chambers  of  Colchester 
records  an  example  of  the  lesion  in  a boy  of  fourteen.  An 
abscess,  containing  two  ounces  of  purulent  matter,  was  found 
deeply  seated  in  the  substance  of  the  heart,  and  extending  from 
auricle  to  auricle  round  the  apex  of  the  organ.  In  an  instance  of 
partial  inflammation  of  the  substance  of  the  heart,  described  by  M. 
Gintrac,  matter  was  formed  in  the  parietes  of  the  left  ventricle  and 
burst  into  the  pericardium. 

Mr  Stallard  of  Leicester  records  an  instance  in  a man  of  60 

* Case  of  Suppuration  of  the  Heart.  By  Richaid  Chambeii,  M.  D.  Lancet, 
1844.  .July  27th.  P.5,57. 


1044 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


years,  who  was  attacked  suddenly,  while  at  work,  with  coma,  cy- 
anosis, and  great  feebleness.  On  the  third  day  death  followed. 
The  heart  was  fat,  flabby,  and  rather  larger  than  usual,  and  the 
pericardium  contained  about  one  ounce  of  dirty  serum.  The 
right  auricle  and  ventricle  were  of  normal  size,  and  the  valves  were 
healthy.  The  lining  membrane  was  of  a deep  violet  or  wine-co- 
loured red.  The  left  ventricle  being  opened,  an  abscess  was  ob- 
served situate  near  the  apex,  of  an  irregular  shape,  being  most 
pointed  towards  the  apex,  from  which  it  was  separated  by  two  or 
three  lines  of  sound  structure.  Above  it  projected  into  the  cavity 
of  the  ventricle,  with  which  it  communicated  by  a small  fissure. 
The  interposed  space  was  one  line  thick,  and  appeared  to  consist 
of  thickened  endocardium.  The  cavity  of  the  abscess  contained 
bloody  purulent-looking  fluid.  Its  lining  membrane  was  of  a light 
red  colour,  and  was  granular  in  appearance.  The  surrounding 
muscular  tissue  was  darker  than  usual,  and  fibrinous  clots  were 
infiltrated.  The  coronary  arteries  were  much  ossified.* 

In  a female  of  35,  who  had  been  suffering  for  some  time  under 
rheumatism  of  the  right  knee,  I found,  with  the  cribriform  state  of 
the  aortic  valves,  in  the  walls  of  the  auricles  near  the  origin  of  the 
aorta,  a cavity  containing  purulent  matter,  and  extending  into  the 
attached  margin  of  the  semilunar  valves.  This  was  caused  by  in- 
flammation of  the  muscular  part  of  the  auricles. 

These  cases  merely  confirm  the  truth  of  the  general  conclusions 
formerly  established  regarding  this  lesion. 

§ 2.  Endocarditis  et  Endocardostia  Valvularum.  Indura- 
Tio  ET  IN  OS  CoNVERSio.  Arctatio  Valvularum. — The  lining 
membrane  of  the  heart  {Endocardium)  is  liable  to  inflammation, 
sometimes  idiopathically,  sometimes  in  consequence  of  rheuma- 
tism. The  effect  of  this  is,  to  render  the  folds,  especially  which 
form  the  mitral  valve  and  sometimes  those  of  the  semilunar 
valves,  thick,  irregularly  tuberculated  with  small  hard  eminences, 
inflexible,  shrivelled,  and  contracted.  At  first  albumen  appears  to 
be  deposited  in  the  interstices  of  the  membranous  folds ; then  the 
folds  are  shrivelled  and  thickened  and  indurated ; the  tendinous 
chords  at  the  same  time  are  shrivelled,  thickened,  and  indurated  ; 
and,  gradually,  the  three  valvular  folds,  by  the  inflammatory  action 
continuing  both  at  their  apices  and  their  base,  produce  disorgani- 

* Observations  on  the  Pathology  of  Abscess  of  the  Pleart,  with  a Case.  By  J.  H. 
Stallard,  Esq.  &c.  Provincial  Transactions,  Vol.  xv.  London,  1847. 


MORBID  STATES  OF  THE  HEART. VALVES. 


]045 


zation  of  the  former,  and  a considerable  degree  of  contraction  in 
the  latter. 

As  this  process  advances,  it  progressively  renders  the  valve  more 
stiff,  hard,  and  unyielding,  until  it  is  converted  into  a sort  of  irre- 
gular ring  of  cartilage  or  bone,  or  cartilaginous  matter,  with  patches 
of  bone  intermixed.  The  valve  is  then  said  to  be  ossified.  The 
auriculo-ventricular  aperture  at  the  same  time  is  so  much  contracted, 
that  the  blood  no  longer  flows  from  the  auricle  into  the  ventricle 
with  its  wonted  facility ; and  a small  quantity  only  passes  into  the 
ventricle,  while  the  auricle  is  kept  in  a constant  state  of  distension, 
and  is  dilated,  and  sometimes  its  w^alls  are  thickened.  In  this  state 
the  auricle  is  said  to  be  affected  with  hypertrophy. 

In  some  instances  the  valve  is  occupied  at  its  apices  with  warty 
tumours  or  growths,  which  have  the  same  effect  in  rendering  it 
stiff  and  immovable. 

The  tendinous  chords  have  been  known  to  give  way  during  great 
efforts,  or  long-continued  running ; and  the  rupture  lays  the  foun- 
dation of  disease  of  the  tendinous  chords  and  the  valve. 

The  change  now  described  may  take  place  at  any  period  of  life ; 
and  it  has  been  observed  in  persons  aged  18,  22,  and  at  all  ages 
under  30.  But  it  is  more  frequent  beyond  40  than  previous  to 
that  age. 

It  seems  very  often  to  be  the  effect  of  inflammation  of  the  lining 
membrane  of  the  heart,  affecting  chiefly  the  valve,  taking  place 
along  with  or  after  rheumatism  ; and  even  when  it  appears  to  take 
place  slowly  in  the  course  of  a long  series  of  years,  it  is  the  effect 
of  chronic  inflammation  of  the  membrane  forming  the  valves. 

The  semilunar  valves,  at  the  origin  of  the  aorta,  are  liable  to  be 
affected  with  the  same  stiffness  and  induration,  and  to  be  penetrated 
by  steatomatous  matter,  cartilaginous  matter,  or  portions  of  calca- 
reous matter.  In  the  beginning,  and  the  slightest  form  of  this  kind 
of  change,  the  semilunar  valves  lose  their  pliancy,  and  can  no 
longer  he  made  to  fold  completely  into  the  axis  of  the  artery. 
This  is  easily  known  in  the  dead  body,  by  pouring  a stream  of 
water  into  the  aorta,  w'hich,  falling  on  the  valves  in  their  healthy 
state,  detaches  them  from  the  sides  of  the  artery,  and  makes  them 
meet  in  the  centre,  so  that  the  column  of  water  is  sustained  by 
them.  When  they  become  rigid,  cartilaginous,  shrivelled,  and 
lose  their  pliancy,  they  cannot  be  detached  in  this  manner  from  the 
the  sides  of  the  vessel,  but  remain  more  or  less  fixed,  so  that  the 
water  passes  from  the  artery  into  the  ventricle.  The  valves  are 


1046 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


thus  inadequate  to  perform  their  function  of  preventing  the  blood 
from  flowing  backwards  into  tbe  ventricle,  when  propelled  from  that 
chamber.  In  more  advanced  stages  of  this  disorder,  the  valves  are 
more  rigid,  more  firm,  and  more  penetrated  by  calcareous  matter ; 
their  margins  become  rough,  irregular  and  tuberculated  or  warty ; 
their  substance  thickened  and  firm,  but  very  much  shrivelled,  so 
that  they  no  longer  retain  either  their  membranous  character  or 
their  semilunar  figure ; they  gradually  are  transformed  into  a ring 
of  firm  cartilaginous  or  calcareous  matter ; and,  at  the  same  time, 
the  orifice  of  the  aorta  is  considerably  contracted.  In  some  in- 
stances, they  remain  in  the  horizontal  position,  as  to  the  axis  of  the 
artery,  projecting  from  its  walls  in  the  form  of  hard  firm  ^’owths, 
and  impeding  much  the  issue  of  blood  from  the  left  ventricle. 

Cartilaginous  or  osseous  degenerations  of  the  semilunar  aortic 
valves  are  not  uncommon  lesions.  They  may  take  place  at  any 
period  of  life  after  the  fortieth  year;  but  are  found  earlier;  and 
are  most  common  in  advanced  life. 

With  or  without  the  changes  now  mentioned  in  the  aortic  semi- 
lunar valves  may  be  observed  steatomatous  and  calcareous  deposits 
at  the  commencement  of  the  aorta,  and  extending  into  the  coronary 
arteries.  In  the  aorta,  these  deposits  may  be  in  the  shape  of  flat 
patches,  or  M^arty  prominences  and  elevations,  and  sometimes  the 
inner  membrane  is  detached,  and  it  is  observed  that  the  blood  has 
been  flowing  over  a hollow  sac  with  a rough  continuous  surface, 
like  a small  and  imperfect  aneurism.  In  some  instances,  these 
patches  are  of  the  nature  of  bony  spiculae,  and  a considerable 
space  of  the  aorta  is  converted  into  a rigid  calcareous  tube. 

The  coronary  arteries  are  occasionally  affected  with  the  same 
deposit ; and  then  become  rigid,  firm,  and  unyielding,  deranging 
the  circulation  through  the  heart,  causing  atrophy  of  the  organ, 
and  rendering  it  feeble  and  unable  to  contract  with  due  force  on 
the  blood.  Such  a change  has  been  supposed  to  give  rise  to  the 
symptoms  of  Angina  pectoris ; but  it  has  been  observed  to  take 
place  without  inducing  any  symptoms,  yet  causing  sudden  death 
either  by  syncope  or  paralysis  of  the  heart. 

These  steatomatous  deposits  consist  of  fat  in  a crystalline  state  or 
chol  ester  in  e. 

Cartilaginous  or  calcareous  transformation  of  the  tricuspid  and 
semilunar  pulmonary  valves  is  much  more  rare;  a fact  noticed  by 
Bichat,  and  repeated  since  his  time  by  most  pathological  writers> 

as  distinctive  of  the  difference  between  the  internal  membrane  of 

6 


MOKBID  STATES  OF  THE  HEART. — VALVULAR  DISEASE.  1047 


the  arterial  system  and  that  of  the  venous.  The  lesion,  however, 
is  not  unknown.  Instances  of  its  occurrence  are  given  by  V ieussens, 
Hunald,  Morgagni,  Bertin,  the  elder  Horn,  Cruwel,  Corvisart, 
Burns,  and  Mr  Bransby  Cooper.  In  a slight  degree,  that  is,  in 
the  state  of  cartilaginous  induration,  it  is  occasionally  observed  in 
the  tricuspid  valve,  and  less  frequently  in  the  semilunar  pulmonary 
valves.  It  is  a remarkable  circumstance,  that  the  cartilaginous  or 
ossified  state  of  the  valves  of  the  right  chambers  of  the  heart  is 
found  chiefly  in  the  persons  of  those  who  present  a preternatural 
communication  between  the  right  and  left  chambers  of  the  organ ; 
and  from  this,  Laennec  infers  that  the  action  of  the  arterial  blood  has 
considerable  influence  in  the  production  of  these  calcareous  deposits. 

Small  granular  bodies  loosely  adhering  to  each  other  are  liable 
to  grow  on  the  valves,  especially  in  the  left  chambers  of  the  heart, 
and  sometimes  from  the  walls  of  the  heart  itself.  These  loose  gra- 
nular bodies,  which  have  been  usually  denominated  warty  growths, 
( verruca J,  and  vegetations,  have  been  ascribed  by  Kreysig,  Ber- 
tin, and  ’^ouillaud  to  the  influence  and  efiects  of  inflammation. 
The  justice  of  this  opinion  Laennec  questions,  though  he  admits 
that  a false  membrane,  produced  by  inflammation,  might  form  in 
some  rare  cases  the  nucleus  or  rudiment,  as  it  were,  of  the  concre- 
tion. Laennec  further  ascribes  these  productions  to  partial  coagu- 
lation of  the  blood.  It  seems  to  me  doubtful,  nevertheless,  whether 
Laennec  has  not  in  this  view  adopted  too  limited  notions  on  the 
nature  of  inflammation.  Though  these  substances  are  so  loose  and 
soft  that  it  is  difficult,  if  not  impossible,  to  preserve  them,  yet  it 
appears  to  me  that  they  may  be  the  result  of  chronic  inflammation 
of  the  lining  membrane  of  the  heart ; and  it  is  some  argument  in 
favour  of  this  idea,  that  these  productions  are  often  associated  with 
other  changes,  which  are  known  to  be  the  result  of  inflammatory 
action ; for  instance,  cartilaginous  and  steatomatous  transformation 
and  calcareous  deposition.  By  Scarpa  and  Corvisart  they  are  as- 
cribed to  the  influence  of  the  syphilitic  poison.  It  is  a well  ascer- 
tained fact  that  they  are  frequent  in  the  bodies  of  those  who  have 
been  subjected  to  the  full  and  repeated  influence  of  mercury. 

The  lesions  now  described  may  exist  for  some  time  alone.  But 
the  most  usual  course  is,  that  they  either  give  rise  to,  or  are  com- 
plicated with,  certain  changes  in  the  dimensions  and  capacity  of  the 
chambers  of  the  heart,  and  various  changes  in  the  muscular  walls 
of  the  organ. 

Thus  when  the  mitral  valve  is  rendered  firm  or  calcareous,  and 


1048 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


the  auriculo-ventricular  aperture  is  contracted,  the  left  auricle  be- 
comes dilated  and  sometimes  hypertrophied,  that  is,  its  walls  become 
thick  and  firm. 

The  most  common  changes  of  this  kind  are  dilatation  of  the  ven- 
tricles, dilatation  of  the  right  chambers,  and  hypertrophy  of  the 
ventricles. 

§ 3.  Atrophy  of  the  Valves. — Perforating  or  Cribriform 
Atrophy.' — The  valves  of  the  aorta  and  the  folds  of  the  mitral 
valve  are  liable  in  certain  circumstances  to  become  extremely  thin, 
and  at  length  to  be  perforated  by  small  irregular  holes.  In  this 
state  they  are  unable  to  perform  their  functions  as  sustaining  and 
resisting  membranous  folds,  against  the  weight  of  the  blood ; and 
not  only  does  the  lesion  cause  regurgitation,  but  the  valves  may 
give  way  and  be  ruptured. 

This  cribriform  state  is  most  common  in  the  aortic  valves ; next 
to  these  in  the  mitral  valve.  It  is  occasionally  seen  in  the  tricus- 
pid valve,  and  sometimes,  though  rarely,  in  the  pulmonary  semi- 
lunar valves.  It  appears  to  be  a species  of  wearing,  the  effect  of 
previous  brittleness  and  attenuation,  and  these  again  the  result 
of  chronic  inflammation. 

§ 4.  Contraction  and  Abridgment. — Under  the  operations 
of  chronic  inflammation  and  aberration  in  nutrition,  the  valves 
are  liable  to  be  not  only  indurated  and  thickened  as  already  de- 
scribed, but  to  be  shortened.  Thus  the  semilunar  valves  at  the 
origin  of  the  aorta  are  liable  to  be  in  this  manner  drawn  together, 
and  shortened.  In  some  instances  two  valves  appear  to  be  united, 
or  to  have  coalesced  into  one ; or  one  is  unusually  short  and  con- 
tracted; or  the  whole  three  may  be  drawn  together  at  their  margins. 
In  the  same  manner  he  ladnice  of  the  mitral  valve  are  liable  to 
become  very  much  shortened,  thickened,  and  drawn  together. 

It  may  be  doubted  whether  this  last  mentioned  change  is  justly  de- 
signated as  atrophy.  It  is  evidently  one  of  the  contracting  eflfects  or 
remote  consequences  of  the  shrivelling  ensuing  in  certain  forms  of 
the  inflammatory  process  in  certain  tissues.  It  appears  to  be  the 
result  of  inflammatory  action  in  the  elastic  fibrous  tissue  of  the 
middle  valvular  tunic. 

These  changes  are  most  frequently  observed  in  the  mitral  and 
aortic  semilunar  valves ; less  usually  in  the  tricuspid  and  pulmo- 
nary semilunar  valves. 

§ 5.  The  latter  are  liable  to  a lesion  of  a very  important  nature 
from  its  connection  with  various  malformations  of  the  heart. 


4 


MORBID  STATES  OF  THE  HEART. — PULMONARY  ARTERY.  1049 


The  orifice  of  the  pulmonary  artery  is  liable  to  three  forms  of 
lesion.  The  first  is  an  unusually  contracted  or  narrow  state  of  the 
cylinder  of  the  artery,  the  capacity  of  which  may  be  not  half  its 
normal  size,  or  at  most  between  that  and  three-fourths.  A second 
is  narrowing,  sometimes  obstruction  even  to  obliteration  of  the 
channel  of  the  artery.  This  is  usually  accompanied  with,  if  not 
caused  by,  more  or  less  thickening  of  the  arterial  walls,  and  may 
be  accompanied  with  some  effusion  of  lymph  or  blood  in  the  inte- 
rior of  the  vessel  at  the  part.  In  some  instances  it  is  like  false 
membrane  uniting  the  opposite  sides  of  the  artery. 

The  third  is  more  or  less  occlusion  of  its  interior  by  coales- 
cence and  mutual  adhesion  of  the  valves.  The  most  usual  form 
of  this  is  for  the  three  semilunar  valves  to  be  united  by  their 
margins,  leaving  at  their  apices  only  a very  moderate  sized  aper- 
ture. Of  this  there  are  various  degrees,  regulated  mostly  by  the 
size  of  the  central  aperture.  In  some  cases  it  is  large  enough  to 
admit  the  tip  of  the  little  finger.  In  others  it  is  so  contracted  that 
it  allows  only  a catheter  of  middle  size  to  pass.  And  in  others, 
the  aperture  is  so  small  that  it  admits  only  a common  probe.  Se- 
veral instances  of  this  lesion  I have  published  ;*  and  others  are  given 
in  the  work  of  Kreysig  on  Diseases  of  the  Heart,  and  in  that  of 
Gintrac  on  Cyanosis.  The  latter  author  mentions  that  the  pul- 
monary artery  was  thus  contracted  in  16  among  53  cases  of  cy- 
anosis, and  in  five  more  the  orifice  was  obliterated. 

The  semilunar  valves  are  in  general  thickened,  and  sometimes 
they  are  indurated.  They  form  in  short  a septum  or  diaphragm, 
perforated  in  the  centre,  stretched  across  the  orifice  of  the  pulmo- 
nary artery. 

The  cause  of  this  lesion  is  not  known.  In  several  cases  it  is  mani- 
festly congenital,  and  must  have  originated  in  the  fcntus.  It  is 
possible  that  at  that  period  when  the  artery  and  its  valves  were 
small,  slight  inflammation  may  have  taken  place  at  the  origin  of  the 
pulmonary  artery,  and  thus  produced  there  mutual  adhesion  and 
coalescence.  If  this  were  the  case,  then  it  is  easy  to  see,  that 
this  lesion  would  keep  the  pulmonary  artery  almost  if  not  wholly  in 
its  foetal  state,  so  that  enlargement  and  expansion  with  the  other 
organs  of  the  body  could  not  advance.  This  might  be  in  different 

* Notice  of  a Case  of  Cyanosis  or  the  Blue  Disease  connected  with  mutual  adhe- 
sion of  the  Semilunar  Valves  of  the  Pulmonary  Artery.  By  David  Craigie,  M.D.,  &c. 
Edinburgh  Medical  and  Surgical  Journal,  Vol.  lx.  p.  265.  Edin.  1843. 


1050 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


degrees;  but  in  all  the  effect  would  be  to  keep  the  orifice  of  the  artery 
more  or  less  obstructed. 

Such  I believe  to  be  the  cause  of  the  coalesced  state  of  the  semi- 
lunar valves  in  cases  of  this  class. 

This  coalition  of  the  valves  is  very  constantly  connected  with 
more  or  less  malformation  of  the  heart,  by  which  the  two  sides  of 
that  organ  communicate.  Thus  it  is  observed  foramen  ovale, 

in  perforation  or  deficiency  of  the  septum,  and  in  cases  in  which 
the  aorta  arises  from  the  right  ventricle,  or  from  both  ventricles  at 
once.  I have  elsewhere  attempted  to  show  that,  taking  into  con- 
sideration all  the  circumstances  of  this  lesion,  it  is  probably  the 
cause  of  these  communications,  or  bears  to  them  such  a relation 
that  the  arctation  of  the  pulmonary  artery  renders  these  communi- 
cations between  the  right  and  left  chambers  requisite. 

In  some  rare  cases  only  two  semilunar  valves  are  found  at  the 
orifice  of  the  pulmonary  artery ; and  Dr  Theophilus  Thomson  re- 
cords a case  of  unusually  large  pulmonary  artery  in  which  it  was 
provided  with  four  valves.* 

§6.  Dilatation  OF  THE  Ventricles,  fv4»2joZ2G^zo,)'pAssivE  aneu- 
rism of  Corvisart,  consists  in  enlargement  of  the  chambers  of  the 
heart,  with  thinning  of  their  walls.  The  muscular  substance  is  at  the 
same  time  unusually  soft  and  flaccid,  sometimes  of  a violet  colour, 
in  other  instances  pale  and  almost  yellowish.  In  such  instances  the 
substance  of  the  heart  must  be  regarded  as  in  a state  of  atrophy, 
hypotrophy,  or  imperfect  nutrition.  The  substance  is  at  the  same 
time  lacerable.  The  extenuation  may  be  so  extreme  that  the  thickest 
part  of  the  ventricle  does  not  exceed  two  lines,  and  the  apex  is 
scarcely  half  a line ; or  the  muscular  substance  may  be  so  stretch- 
ed, attenuated,  and  absorbed,  that  nothing  but  a little  fat  covered 
by  pericardium  retains  the  blood.  Laceration,  in  such  circum- 
stances, as  Burns  imagined,  seems  not  impossible ; yet  neither  Cor- 
visart nor  Laennec  met  with  any  instance  of  this  accident  in  conse- 
quence of  dilatation  of  the  left  ventricle  ; and  in  none  of  the  record- 
ed instances  of  rupture  does  the  accident  appear  to  have  been  the 
result  of  extenuation,  so  much  as  friability  or  ulceration. 

This  disease  M.  Bertin  ascribes  to  the  operation  of  obstacles  or 
impediments  to  the  circulation ; for  instance,  ossification  of  the 
valves,  and  arctation  of  their  apertures,  congenital  straitness  of  the 
pulmonary  artery  or  the  aorta,  professions  requiring  painful  efforts, 

* Account  of  a Case  of  Irregular  Formation  of  the  Heart,  &c.  By  Theophilus  Thom- 
son, M.D.  Medico-Chirurgical  Transactions,  vol.  xxv.  p.  247.  London,  1842. 


MORBID  states  OF  THE  HEART HYPERTROPHY.  1051 


and  certain  diseases  of  the  lungs,  as  consolidation  and  tubercular 
induration.  Though  the  influence  of  these  causes  is  considerable, 
the  most  general  and  the  most  powerful  is  original  conformation  ; 
that  is,  an  unusually  narrow  pulmonary  artery  as  to  the  right  ven- 
tricle, and  a narrow  aortic  orifice  as  to  the  left  ventricle.  Several 
instances  of  passive  dilatation  of  the  left  ventricle,  1 have  seen  as- 
sociated with  ossification  of  the  aortic  semilunar  valves,  and  conse- 
quent arctation  of  the  orifice.  When  the  right  ventricle  is  dilated, 
the  lesion  is  usually  connected  with  more  or  less  disease  of  the 
lungs  ; and  the  right  auricle  becomes  at  length  affected  in  the  same 
manner, 

§ 7.  Hypertrophy  or  excessive  nutrition  of  the  heart  maybe  said 
to  consist  in  increased  thickness  of  the  muscular  substance  of  the 
organ,  which  is  at  the  same  time,  in  general,  firmer  and  more  dense 
than  natural.  It  may  exist  in  one  ventricle  only,  or  extend  to 
both  ; and  it  may  be  general  or  partial.  When  the  left  ventricle 
is  affected,  it  may  exceed  one  inch,  or  be  even  eighteen  lines  in 
thickness  at  the  base,  which  is  fully  double  or  three  times  thicker 
than  in  the  natural  state.  When  the  ventricle  is  generally  afiect- 
ed,  it  is  thickest  at  the  base,  and  diminishes  gradually  to  the  apex ; 
but  the  apex  sometimes  participates  to  the  extent  of  from  two  to 
four  lines.  If  the  apex  is  affected,  the  disease  is  generally  local. 
In  other  instances,  partial  thickening  appears  most  commonly  in 
the  neighbourhood  of  the  valves.  In  the  case  of  the  right  ventri- 
cle, the  increased  thickness  is  more  uniform,  extending  over  the 
whole,  and  rendering  it  so  firm  as  not  to  collapse  when  cut  open. 
The  preternatural  change,  however,  is  always  most  distinct  in  the 
neighbourhood  of  the  tricuspid  valve,  and  in  that  part  of  the  ven- 
tricle which  gives  origin  to  the  pulmonary  artery.  The  bulk  of 
the  fleshy  pillars  (columnae  carneae)^  is  always  much  increased ; 
and  this  condition,  which  is  more  conspicuous  than  in  the  left,  with 
the  great  firmness  of  the  muscular  substance,  forms  a striking  fea- 
ture in  the  anatomical  characters  of  hypertrophy  of  the  right  ven- 
tricle. 

Hypertrophy  has  been  distinguished  by  M.  Bertin  into  three 
forms,  according  to  the  effect  it  exerts  on  the  capacity  of  the  cham- 
bers of  the  heart,  or  according  to  the  mode  in  which  the  increased 
deposit  of  material  is  applied; — Is#,  simple  hypertrophy;  2d,  ex- 
centric  hypertrophy ; and  Zd,  concentric  hypertrophy. 

In  the  first  form,  the  walls  of  one  or  more  of  the  chambers  of 


1052 


GENERAL  AND  PAXnOLOGICAL  ANATOMAL 


the  heart  are  thickened,  while  the  chambers  are  neither  enlarged 
nor  diminished  in  capacity.  This  is  simple  hypertrophy,  in  which 
the  increase  of  matter  may  be  regarded  as  applied  from  the  inner 
surface  outwards. 

In  the  second  form,  the  walls  of  the  chambers  are  thickened, 
while  the  capacity  of  these  cavities  is  enlarged.  This  is  excentric 
hypertrophy,  in  which,  with  the  increase  of  matter  from  within  out- 
wards, there  is  exerted  in  the  same  direction  a dilating  or  dis- 
tending force.  This  corresponds  with  the  active  aneurism  of  Cor- 
visart. 

In  the  third  form  of  the  disorder,  the  thickening  of  the  walls  of 
the  heart  is  combined  with  diminution  in  the  capacity  of  the  ven- 
tricles, as  if  the  new  matter  had  been  added  chiefly  to  the  interior 
of  the  ventricle,  or  had  been  deposited,  at  least,  from  the  exterior 
to  the  interior  surface.  This  is,  therefore,  named  concentric  hyper- 
trophy. 

No  doubt  has  ever  been  entertained  as  to  the  existence  of  the 
two  first  forms  ; for  instances  of  simple  hypertrophy  have  been  ob- 
served by  Morgagni,  Corvisart,  and  others,  though  they  have  not 
been  carefully  distinguished ; and  excentric  hypertrophy  is  by  far 
the  most  common  lesion  to  which  the  heart  is  liable.  It  is  diffe- 
rent with  concentric  hypertrophy,  the  existence  of  which  has  been 
called  in  question  by  Cruveilhier  in  France,  and  Dr  Eudd  in  this 
country,  both  of  whom  ascribe  to  the  mode  and  circumstances  in 
which  death  takes  place,  the  appearance  deemed  characteristic  of 
that  lesion. 

Cruveilhier  has  observed  in  the  bodies  of  those  who  had  suffered 
death  by  decapitation  and  those  cut  off  by  violent  death,  the  two 
phenomena  of  great  contraction  or  even  obliteration  of  the  ven- 
tricle, and  proportional  thickness  of  the  walls  of  the  heart,  and  he 
infers,  therefore,  that  these  phenomena  are  the  effect  of  this  species 
of  death,  and  regards  the  concentrically  hypertrophied  hearts  of  M. 
Bertin  and  Bouillaud  as  hearts  more  or  less  hypertrophied  in  per- 
sons overtaken  by  death  in  the  full  energy  of  contraction.  He 
further  argues,  that,  as  it  is  always  possible  to  open  and  dilate  these 
hearts  apparently  without  cavity,  by  introducing  several  fingers, 
these  circumstances  indicate  more  forcibly  that  the  state  of  the 
heart  is  the  effect  of  the  last  vital  contractions.* 

Dr  Budd,  finding  that  in  such  hearts  the  ventricle  becomes  re- 
* Dictionnaire  de  Medecine,  Art.  Hypertrophie. 


MOBBID  STATES  OF  THE  HEART — MORIBUND  CONTRACTION.  1053 

laxed  to  its  usual  capacity  after  the  heart  had  been  macerated 
a few  days,  and  that  during  life  there  was  no  intermittence  or 
irregularity  of  pulse,  no  dilatation  of  the  right  cavities,  and  no 
symptoms  of  impediment  to  the  circulation,  arrives  at  the  same 
conclusion.* 

It  cannot  be  denied,  that,  in  various  instances  of  sudden  death, 
as  death  by  hemorrhage,  and  also  in  many  instances  of  death  by 
cholera,  the  left  ventricle  is  found  in  this  greatly  contracted  state, 
hard,  firm,  with  thick  walls,  and  almost  no  cavity,  the  internal  sur- 
faces of  the  ventricle  being  closely  applied  to  each  other,  and  the 
ventricle  being  entirely  empty.  It  is  also  to  be  observed,  that  this 
state  of  the  heart  is  found  in  persons,  in  whom  none  of  the  usual 
symptoms  of  disease  of  the  heart  were  observed  to  take  place  during 
life,  and  consequently  in  whom  the  existence  of  such  a lesion  was 
not  suspected.  It  may  be  admitted,  then,  that,  in  a certain  number 
of  cases,  especially  where  this  state  of  the  heart  is  found  after  vio- 
lent death,  sudden  death  by  hemorrhage,  or  sudden  death  from 
other  causes,  it  is  not  positively  indicative  of  a peculiar  morbid  state 
of  the  heart  during  life. 

It  seems,  nevertheless,  a conclusion  too  violent  to  infer,  that,  of 
all  cases  in  which  this  state  of  the  heart  is  found,  none  is  to  be  re- 
garded as  the  effect  of  morbid  thickening  of  the  ventricle  with  con- 
traction of  its  chambers.  M.  Bouillaud,  accordingly,  who  maintains 
the  correctness  of  the  views  of  M.  Bertin,  records  in  his  work  on 
Diseases  of  the  Heart,  eight  cases  of  concentric  hypertrophy  of 
the  right  ventricle,  and  five  of  concentric  hypertrophy  of  the  left 
ventricle. 

I have  met  with  a few  cases  of  this  state  of  the  heart,  indepen- 
dent of  those  which  I observed  in  the  bodies  of  persons  destroyed 
by  cholera;  and  in  the  Clinical  Report  for  1832-1833,  are  men- 
tioned three  cases,  in  two  of  which  I think  no  doubt  could  be  ex 
tertained  of  the  existence  of  this  lesion.  In  the  one  case,  in  which 
death  was  caused  by  granular  disease  of  the  kidney,  the  cavity  of 
the  left  ventricle  was  almost  obliterated  by  the  close  mutual  appli- 
catiou  of  the  walls,  which  were  very  thick,  firm,  and  hard.  In  the 
other  case,  in  which  death  was  caused  by  an  attack  of  erysipelas, 
the  cavity  of  the  ventricle  was  equally  contracted,  and  its  walls 
were  nearly  as  thick  and  firm  as  in  the  former ; and  the  patient  had 
presented  during  life  symptoms  of  angina  peetoris.\ 

* Medico-Chirurg.  Transact.  Vol.  xxi.  London,  1838. 

t Clinical  Report  for  1832-1833,  Edinburgh  Med.  and  Surg.  Journal. 


1054 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


Excentric  or  aneurisinal  hypertrophy  is,  nevertheless,  by  far  the 
most  common  lesion ; and  the  extent  to  which  the  heart  may  be 
enlarged  by  it  is  very  great.  The  circumference  of  the  base  of 
the  heart  may  amount  to  from  12  to  16  inches  ; its  transverse  dia- 
meter, 6 or  9 ; and  the  longitudinal  diameter,  from  base  to  apex, 
from  5 to  7 inches. 

The  increase  in  weight  is  the  most  conspicuous  change.  The 
minimum  weight  of  the  adult  heart  is  about  6 ounces  2 drachms ; 
the  average  weight  about  8 ounces.  In  the  state  of  hypertrophy, 
however,  the  weight  is  increased  to  12  or  13  ounces  at  least,  and 
may  be  so  great  as  22,  26,  or  28  ounces.  The  average  of  seven- 
teen cases  recorded  by  Bouillaud  amounts  to  16  ounces.  The  thick- 
ness of  the  walls  of  the  left  ventricle  varies  from  7 to  14  lines. 
The  thickness  of  those  of  the  right  ventricle  varies  from  3 to  5 lines. 

This  lesion  gives  rise  to,  or  is  connected  with,  others  very  im- 
portant to  be  known.  It  is  often  associated  with  a bloody  or  hemor- 
rhagic consolidation  of  the  lungs  and  haemoptysis ; and,  in  a con- 
siderable proportion  of  cases,  it  gives  rise  to  softening  or  hemor- 
rhage in  the  brain. 

Excentric  hypertrophy  is  often  associated  with  cartilaginous  or 
calcareous  degeneration  of  the  semilunar  aortic  valves,  and  some- 
times with  that  of  the  mitral  valve. 

Excentric  hypertrophy  is,  in  a large  proportion  of  instances,  the 
result  of  rheumatism  affecting  the  heart,  and  giving  rise  to  endo- 
carditis. This  can  in  general  be  known  by  the  fact,  that  the  indi- 
vidual has  suffered  rheumatic  pains  in  the  wrists  and  ankles,  or  in 
the  elbows  and  knees,  previous  to  the  appearance  of  the  symptoms 
of  hypertrophy.  In  some  cases,  hypertrophy,  adhesion  of  the  pe- 
ricardium to  the  heart,  and  valvular  disease,  are  united  in  the 
same  individual. 

§ 8.  Partial  Aneurism,  or  Consecutive  False  Aneurism. — 
This  consists  in  a portion  of  the  muscular  fibres  of  the  heart  giving 
way,  so  as  to  form  in  the  muscular  walls  of  the  organ  a cavity,  sac, 
or  pouch,  communicating  by  an  opening  with  the  cavity  of  the 
chamber,  in  the  walls  of  which  the  pouch  has  been  formed. 

This  change  may  take  place  in  any  part  of  the  muscular  sub- 
stance of  the  heart ; but  it  is  most  usually  seen  in  the  left  ventricle, 
near  or  towards  the  apex.  In  various  affections  of  the  heart,  but 
especially  in  dilatation,  with  more  or  less  disease  of  the  aortic  se- 
milunar valves,  it  is  not  uncommon  to  observe,  formed  near  the 
apex  of  the  left  ventricle,  small  cavities  or  pouches,  while  the  mus- 


MORBID  STATES  OF  THE  HEART — PARTIAL  ANEURISM.  1055 


cular  walls  at  that  part  are  rendered  extremely  thin.  These  cavities, 
which  contain  blood  in  the  shape  of  adherent  clots,  are  formed  by  a 
gradual  separation  of  the  muscular  fibres  and  some  degree  of  dila- 
tation ; but  no  laceration  or  breach  of  continuity  is  in  general  to 
be  perceived. 

It  is  different  with  partial  aneurism.  The  muscular  fibres  un- 
dergo an  interruption  or  solution  of  continuity  in  the  transverse 
direction  quite  perceptible  ; and  by  their  retraction  and  separation, 
a cavity  or  pouch,  variable  in  size  and  shape,  but  generally  round 
or  ovoidal,  is  formed  in  the  walls  of  the  heart.  In  some  instances 
the  fibres  are  completely  destroyed,  and  the  outer  wall  of  the  pouch 
is  formed  by  the  pericardium  alone.  This  appears  to  have  taken 
place  in  a case  by  M.  Dance,  and  in  the  case  of  the  actor  Talma. 

The  interior  of  these  pouches  or  cavities  in  the  walls  of  the  heart 
may  be  filled  with  coagulated  blood,  adherent  to  the  walls,  and,  in 
some  instances,  arranged  in  the  form  of  lamincB,  as  in  aneurism  of 
arteries.  In  some  instances  they  are  empty,  or  contain  only  a 
little  clotted  blood  or  blood  plasma  adhering  to  the  walls  of  the 
pouch. 

This  lesion  generally  takes  place  in  the  anterior  or  lateral 
part  of  the  walls  of  the  left  ventricle,  or  near  the  apex  in  the  an- 
terior and  left  side.  In  ten  cases  among  seventeen  well-marked  in- 
stances of  the  disease  collected  by  myself,  the  tumour  was  situate 
near  or  formed  in  the  apex.  In  a few  cases  it  is  found  in  the  sep- 
tum cordis.  In  one  case  which  was  under  my  own  care,  the  pouch 
or  sac  was  formed  in  the  base  of  the  septum  ;*  and  it  formed  a 
large  round  prominence  in  the  right  ventricle.  In  an  instance 
given  by  Dr  Pereira,  tbe  cavity  was  formed  in  the  substance  of  the 
septum.,  and  consisted  of  four  subordinate  pouches,  one  of  which 
had  burst  into  the  right  ventricle.f  Mr  Thurnam  mentions  three 
instances,  also  in  the  septum^X  and  Bouillaud  gives  one.§  In  a 
case  given  by  Zannini,  tbe  origin  of  the  aneurismal  tumour  was 

* Observations  and  Cases  illustrating  the  Nature  of  False  Consecutive  Aneurism  of 
the  Heart.  By  David  Craigie,  M.  D.  Edinburgh  Medical  and  Surgical  Journal,  Vol. 
lix.  p.  366.  Edinburgh,  1843. 

-(•  Case  of  Partial  Aneurism  of  the  Left  Ventricle  of  the  Heart.  By  Jonathan  Pe- 
reira. Medical  Gazette,  October  1845,  and  Edinburgh  Aled.  and  Surg.  Journal,  Vol. 
Ixvi.  p.  503.  Edinburgh,  1846. 

J On  Aneurisms  of  the  Heart,  with  Cases.  By  John  Thurnam.  Medico-Chirm- 
gical  Transactions,  Vol.  xxi.  p.  187.  London.  1838. 

§ Traite  Clinique  des  Maladies  du  Coeiu.  Par  J.  Bouillaud.  Paris,  1835.  2ieme 
Edition.  Tome  i.  p.  594.  Pans,  1841. 


1056 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


situate  in  the  lower  end  of  the  septum,  and  extended  into  the  apex 
formed  by  the  walls  of  the  heart.* 

In  size  these  aneurismal  pouches  vary.  Some  are  small,  not 
larger  than  a gooseberry ; others  are  much  larger,  and  make  a 
large  projecting  tumour  externally,  altering  much  the  usual  figure 
of  the  heart. 

The  disease  has  been  observed  in  general  in  persons  above  25  ; 
and  several  of  the  cases  have  occurred  in  persons  advanced  in  life. 
In  only  one  case  among  58  was  the  patient  under  20  years.  In  the 
case  given  by  Dr  Pereira,  the  disease  took  place  in  a girl  of  15 
years,  which  is  the  earliest  period  yet  recorded  at  which  it  has  been 
observed. 

Partial  aneurism  of  the  heart  is  generally  associated  with  other 
lesions  of  that  organ  and  its  valves.  Thus  the  aortic  valves  are 
very  generally  rigid,  steatomatous,  or  penetrated  with  specks  and 
patches  of  bone.  In  some  instances  they  are  cribriform  or  perfo- 
rated by  holes.  In  a few  cases,  the  mitral  valve  is  rigid  and  slightly 
ossified.  In  most  cases,  the  lining  membrane  is  more  or  less  thick- 
ened, and  not  unfrequently  white  opaque  spots  in  it  are  visible. 
Round  the  pouch  itself  there  is  usually  observed  a layer  of  fibres, 
rough,  firm,  and  rigid,  not  unlike  horse-hair.  The  ventricle, 
either  right  or  left,  is  usually  in  a state  of  hypertrophy.  In  the 
case  examined  by  myself,  the  heart  weighed  with  the  aorta  32 
ounces ; and  if  for  the  latter  one  ounce  and  a half  or  two  ounces 
be  deducted,  it  makes  the  heart  30  ounces,  which  is  about  three 
times  more  than  the  average  weight  of  the  adult  heart  in  a state  of 
health. 

Upon  the  mode  in  which  these  pouches  are  formed,  it  is  not  easy 
to  give  a decided  opinion.  It  seems  certain  that,  in  most  instances, 
the  muscular  fibres  of  the  heart  are  lacerated  transversely,  and  se- 
parated in  their  longitudinal  direction.  When  the  pouches  are 
carefully  examined,  one  portion  of  the  sac  is  always  more  or  less 
distinctly  formed,  by  what  we  know  must  be  the  ends  of  the  con- 
torted muscular  fibres  of  the  heart.  These,  it  is  true,  are  lined 
or  covered  by  lymph  and  blood ; but  when  this  is  removed,  and 
even  sometimes  without,  it  is  possible  to  trace  the  fibres  ending 
abruptly. 

On  the  mode  in  which  the  laceration  takes  place,  or  the  causes 
by  which  it  may  be  produced,  much  difference  of  opinion  prevails 

■*  Observations  and  Cases,  &c.  By  Dr  Craigie.  Case  9. 


MORBID  STATES  OF  THE  HEART PARTIAL  ANEURISM.  1057 

among  writers  on  pathology.  M.  Breschet,  regarding  it  as  false 
consecutive  aneurism  of  the  heart,  and,  therefore,  analogous  to  the 
false  consecutive  aneurism  of  the  arteries,  studies  to  illustrate  its 
nature  and  origin  by  appealing  to  the  history  of  the  cases  of  rupture 
or  laceration  of  the  heart.  Many  instances  of  this  lesion  have  been 
recorded,  and  the  successive  observations  of  Harvey,  Lancisi,  Ver- 
bruggen, Morgagni,  Senac,  Lieutaud,  Morand,  Portal,  Corvisart, 
and  recently  of  Perms,  Laennec,  Kostan,  Blaud,  Bayle,  and  the 
two  MM.  Rochoux,  have  furnished  so  much  information  on  the 
circumstances,  in  which  rupture  is  most  likely  to^take  place,  that 
we  cannot  expect  to  know  much  more  on  that  subject.  It  is 
known  that  these  accidents,  though  they  may  occur  in  any  part  of 
the  organ,  are,  nevertheless,  by  far  the  most  common  in  the  left 
ventricle,  and  especially  at  the  apex.  This  circumstance  is  proba- 
bly to  be  ascribed  at  once  to  the  greater  thinness  and  weakness  of 
the  parietes  at  the  apex,  and  to  the  strength  and  energy  with  which 
the  left  ventricle  contracts.  It  is  almost  clear  to  demonstration, 
that,  of  any  muscular  organ,  of  which  the  greater  part  is  thick  and 
strong  in  structure,  and  forcible  in  action,  while  one  part  is  a little 
thinner,  the  latter  is  most  likely  to  give  way  during  any  action  of  the 
organ  unusually  forcible  or  violent.  This  will,  of  course,  be  much 
more  likely  to  happen  where  either  unusual  resistance  is  presented, 
as  in  disease  of  the  aortic  valves,  or  where  the  action  is  morbidly 
increased  from  morbid  though  partial  increase  in  the  thickness  of 
the  parietes  of  the  heart. 

M.  Breschet  seems  to  think  that  the  position  of  these  lacerations 
may  be  employed  to  explain  the  origin  of  the  false  consecutive 
aneurism  of  the  heart,  and  he  directs  attention  to  the  important 
fact,  that,  in  the  ten  cases  which  he  records,  and  most  of  which  are 
abridged  in  the  memoir  referred  to,  in  most  the  lesion  was  situate  at 
or  near  the  apex  of  the  left  ventricle.  The  right  ventricle,  he  ob- 
serves, presents  nothing  of  this  nature,  nor  did  his  researches  bring 
him  acquainted  with  any  instance  of  its  occurrence  in  the  right  ven- 
tricle. He  allows,  however,  that  we  are  not  entitled,  from  so  small 
a number  of  cases,  to  deduce  any  very  positive  conclusions. 

M.  Breschet,  nevertheless,  very  properly  refers  to  three  condi- 
tions which  have  been  believed  to  be,  almost  necessarily  implied  in 
tbe  sort  of  lesion  now  described.  These  are ; Isif,  softening  of  the 
tissue  of  the  heart,  that  is,  of  its  muscular  fibres ; 2d,  ulceration  of 
the  inner  membrane  ; and  3rf,  rupture  of  the  muscular  fibres ; and 

3 X 


1058 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


while  he  questions  the  effective  operation  of  the  two  former,  he  ad- 
vocates somewhat  strongly  the  influence  of  the  third  cause.  I must 
refer  my  readers  to  the  original  paper  for  the  arguments  hy  which 
he  maintains  the  justice  of  his  cause. 

In  point  of  fact,  while  Mr  Thurnam  has  shown  that  this  spe- 
cies of  aneurismal  dilatation  or  rupture  may  occur  not  only  in  the 
left  ventricle,  but  in  the  right,  and  also  in  the  auricles,  the  22d 
case  which  is  recorded  in  the  memoir  by  the  author,  and  the  in- 
stances of  the  lesion  taking  place  in  the  septum  cordis^  prove  that 
the  lesion  may  take  place  not  merely  at  the  apex  of  the  heart,  but 
at  the  base  of  the  septum.  It  must  be  allowed,  therefore,  that, 
though  the  lesion  is  most  liable  to  take  place  at  or  near  the  apex 
of  the  left  ventricle,  it  may  be  found  in  other  parts  of  the  heart, 
and  consequently  that  the  circumstances  concerned  in  its  production 
must  be  applicable  not  to  the  apex  only,  but  to  other  parts. 

By  M.  Bouillaud  an  idea  somewhat  different  has  been  ad- 
vanced, viz.  that  the  false  consecutive  aneurism  of  the  heart  is  one 
of  the  effects  or  terminations  of  inflammation  in  the  muscular  sub- 
stance of  the  heart  This  author  informs  us,  ‘‘  that  the  formation 
of  an  aneurismal  cyst  consecutive  to  ulceration  of  the  internal  and 
middle  membranes  of  the  heart,  is  accomplished  by  the  same  me- 
chanism as  that  of  an  aneurismal  cyst  of  the  arteries.  The  lamel- 
lar disposition  of  the  coagulura  is  exactly  the  same  in  the  false 
consecutive  aneurism  of  the  heart,  as  in  the  false  consecutive  aneu- 
rism of  the  arteries,  I need  not,  therefore,  dwell  at  length  here 
on  the  anatomical  description  of  this  accident  of  the  ulcerations  of 
the  heart.  The  tumour  formed  by  the  blood  infiltrated  and  coa- 
gulated is  very  different  in  quantity.  Thus  it  may  in  some  instances 
not  be  equal  to  the  size  of  a walnut  or  filbert,  while  in  other  cases 
it  exceeds  the  bulk  of  an  egg,  and  may  even  be  greater  than  that 
of  the  two  ventricles  together.” 

It  cannot  be  denied  that  this  mode  of  explaining  the  origin  of 
the  aneurismal  cysts  of  the  heart  is  to  a certain  extent  plausible. 
Several  of  these  cysts  present  appearances  of  ulceration  ; and  if  it 
could  be  proved  that  the  ulceration  always  precedes  the  formation 
of  the  cysts,  and  is  always  the  effect  of  previous  inflammation,  the 
question  would  be  decided.  This  is,  however,  very  far  from  being 
the  fact,  or  the  constant  result  in  all  cases.  Not  only  do  instances 
of  aneurismal  cysts  in  the  substance  of  the  heart  take  place  without 
any  indications  of  previous  inflammation  or  ulceration  ; but  in  seve- 
ral of  the  cases,  indeed  the  majority,  the  lesion  exists  for  a long 


MORBID  STATES  OP  THE  HEART PARTIAL  ANEURISM.  1059 


time  without  presenting  any  of  the  symptoms  of  the  inflammatory 
or  ulcerative  process.  Thus,  in  the  well-known  case  of  Talma, 
there  was  no  indication  of  previous  inflammation  or  ulceration,  and 
after  it  had  taken  place,  and  lasted  for  at  least  three  years,  it  did  not 
indicate  its  presence  by  any  very  marked  symptom  of  any  kind,  and 
assuredly  by  none  indicating  the  presence  of  inflammatory  action, 
either  acute  or  chronic.  In  almost  all  the  other  cases  also  no  con- 
spicuous or  urgent  symptoms  took  place  to  denote  the  exact  date 
of  the  commencement  of  the  lesion,  which  has,  in  most  instances, 
been  discovered  unexpectedly  in  examining  the  heart  after  death. 

It  must  be  allowed,  nevertheless,  that  the  inflammatory  process, 
without  proceeding  to  ulceration,  as  Bouillaud  requires,  may  have 
a tendency  to  produce  this  lesion,  by  the  change  which  it  effects 
on  the  tissues,  in  which  it  is  seated.  It  is  one  of  the  most  con- 
stant, perhaps,  of  the  properties  of  this  process,  to  impair  or  destroy 
the  tenacity,  elasticity,  cohesion,  and  resisting  power  of  the  animal 
tissues,  and  in  none  more  decidedly  than  in  the  muscular.  All 
textures  after  inflammation  are  rendered  more  fragile  and  more 
lacerable.  This  is  particularly  the  case  with  the  arterial  tunics, 
with  tendons,  with  cartilages,  and  with  the  bones,  and  above  all, 
with  the  muscular  tissue,  which  becomes  less  distensible,  less  con- 
tractile, and  more  rigid  than  before.  It  is  possible  that  some  new 
deposit  may  have  been  formed  in  it.  But  even  this  does  not  seem 
necessary ; and  the  simple  pre-existence  of  the  inflammatory  con- 
gestion appears  to  be  all  that  is  requisite  to  induce  this  sort  of 
lacerability. 

It  is  not  improbable  that  these  facts  and  considerations  appear- 
ed so  conclusive  to  M.  Cruveilhier,  that,  in  proposing  another  cir- 
cumstance as  a preliminary  or  predisposing  cause  of  false  consecu- 
tive aneurism,  he  found  it  difficult,  if  not  impracticable,  to  exclude 
the  influence  of  the  inflammatory  process.  From  various  pheno- 
mena presented  by  the  tumours  and  cysts  in  this  lesion,  but  espe- 
cially from  the  phenomena  presented  by  the  preparation  described 
in  Case  17  in  the  memoir  by  myself,  he  infers  that,  in  every  instance 
of  false  consecutive  or  partial  aneurism  of  the  heart,  one  of  two 
processes  is  in  operation  ; one  the  inflammatory  action,  and  the  other 
the  fibrous  transformation  of  the  muscular  tissue  of  the  heart.  To 
the  latter,  however,  which  he  believes  to  be  often  primary  or  idio- 
pathic, and  not  accompanied  by  inflammation,  he  assigns  the  prin- 
cipal place.  Numerous  facts,  he  informs  us,  lead  him  to  conclude 


1060 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


that  the  idiopathic  fibrous  transformation  of  the  muscular  fibres  of 
the  heart  performs  a greater  part  in  the  formation  of  partial  aneu- 
rism than  inflammation  ; and  if  the  apex  of  the  heart  be  often  the 
seat  of  the  lesion,  the  reason  is,  that  it  is  the  weakest  part  of  the 
left  ventricle,  and  therefore  the  most  frequent  seat  of  the  fibrous 
transformation,  so  common  a consequence  of  distension  of  the  mus- 
cular tissue. 

The  reason  why  the  right  ventricle,  he  adds,  is  less  frequently 
affected  by  partial  dilatation  is,  that  its  walls  are  less  thick,  and  its 
structure  more  areolar  than  that  of  the  left  ventricle.  The  vigour 
and  force  with  which  the  left  ventricle  contracts  is  the  anatomico- 
physiological  cause  of  its  predisposition  to  this  disease. 

When  the  fibrous  transformation  has  commenced  in  one  point  of 
the  walls  of  the  heart,  he  infers  that  the  distension  which  takes 
place  at  each  contraction  becomes  an  incessant  cause  of  irritation  ; 
and  there  are  formed  in  this  non-contractile  sac  clots  which  may 
serve  as  a barrier  to  oppose  the  enlargement  of  the  tumour.  He 
adds  that  he  has  seen  cases,  in  which  the  shape  of  the  heart  was  not 
sensibly  altered  externally,  though  its  apex  presented  the  com- 
mencement of  this  fibrous  sac  or  recess,  and  the  presence  of  such  a 
state  had  been  denoted  by  no  symptom  during  life.  The  correct- 
ness of  this  observation  I can  confirm  from  personal  knowledge ; 
and  of  this  the  case  of  the  young  man.  No.  21,  which  occurred 
in  my  own  practice,  is  an  excellent  example. 

When,  however,  the  part  thus  transformed  into  fibrous  tissue  is 
dilated  into  a sac  superadded  to  the  ventricle,  or  pushed  beyond 
the  level  of  its  internal  surface,  yet  communicating  with  its  cavity 
by  a narrow  orifice,  it  constitutes  the  partial  aneurism  described 
by  authors. 

M.  Cruveilhier,  however,  does  not  apply  to  all  these  tumours  the 
name  of  false  consecutive  aneurism ; and  he  makes  a distinction 
between  this  and  partial  aneurism  of  the  heart.  By  partial  aneur- 
ism of  the  heart,  M.  Cruveilhier  understands  dilatation  of  one 
portion  of  the  heart  into  a cyst,  in  consequence  of  the  fibrous 
transformation  of  the  tissue  of  the  organ.  These  parts,  however, 
may  become  eroded,  and  hence  may  be  lacerated ; and  while  the 
cardiac  pericardium  prevents  complete  rupture,  either  alone  or  by 
its  having  contracted  adhesion  with  the  capsular  pericardium,  the 
partial  aneurism  of  the  heart  would  then  be  converted  into  false 
consecutive  aneurism.* 

* Cruveilhier  Anatomie  Pathologique,  Livraison  xxi. 


MORBID  STATES  OF  THE  HEART. — PARTIAL  ANEURISM.  1061 

He  maintains  also  that  the  partial  aneurism  of  the  heart  com- 
mences always  by  dilatation,  and  ought,  therefore,  to  be  regarded 
as  a true  aneurism. 

Throwing  aside  this  distinction  in  the  meantime,  it  must  be  ad- 
mitted, that  the  point  for  which  M.  Cruveilhier  contends,  as  the 
main  predisposing  cause  of  aneurism  of  the  heart,  namely  the  pre- 
vious fibrous  transformation  of  the  muscular  tissue,  is  one  which 
derives  considerable  force  from  the  appearance  of  many  of  the  ex- 
amples of  the  lesion.  In  the  majority  of  these,  the  aneurismal 
sac  or  cyst  has  presented,  as  in  the  17th  case  of  the  essay,  more  or 
less  of  the  fibrous  structure.  In  the  case  which  occurred  in  my 
own  practice,  this  fibrous  transformation  was  remarkably  distinct, 
both  on  the  side  of  the  left  ventricle,  and  also  on  that  of  the  right, 
most  so  certainly  in  the  latter,  where  it  formed  a firm  strong  pro- 
minent mass,  convex  in  shape  towards  the  right  ventricle.  This 
fibrous  structure  was  also  distinctly  visible  and  very  strong  at  the 
margin  of  the  opening  of  the  sac  into  the  left  ventricle.  In  all  the 
cases  detailed  in  ray  own  memoir,  the  fibrous  structure  is  remarked 
at  the  margin  of  the  orifice  of  the  cyst,  which  is  described  as  firm, 
elevated,  and  generally  whitish. 

The  only  question  for  consideration  would  appear  to  be,  whether 
has  this  fibrous  transformation  taken  place  before  the  aneurismal 
dilatation  or  after  its  occurrence  ? I am  not  sure  that  any  of  the 
facts  which  I have  recorded,  or  which  have  come  to  my  knowledge, 
are  capable  of  determining  this  point. 

With  regard  to  the  other  point  maintained  by  M.  Cruveilhier, 
viz.  the  distinction  between  true  or  partial  aneurism  of  the  heart 
and  false  consecutive  aneurism  of  the  heart,  it  appears  to  me  that, 
in  the  present  state  of  knowledge,  it  must  be  considered  as  a 
distinction  rather  in  the  degree  and  stage  than  in  the  nature  and 
kind  of  the  lesion.  Several  of  these  aneurismal  cysts  appear  to 
commence  at  first  by  slight  laceration,  and  then  to  be  enlarged  by 
dilatation.  Several,  on  the  other  hand,  especially  those  near  the 
apex  of  the  heart,  appear  to  commence  first  by  dilatation,  and 
then  to  be  enlarged  by  some  degree  of  laceration.  In  many  the 
two  processes  are  conjoined ; and  it  seems  difficult  to  say  which 
of  them  is  the  first.  It  is  admitted  even  by  M.  Cruveilhier  him- 
self, that  the  form  of  the  disease  which  he  denominates  partial 
aneurism  is  earlier  and  less  advanced  than  that  named  false  con- 
secutive aneurism,  and  in  which  the  fibrous  transformation,  not 
yet  effected  in  the  former,  is  far  advanced  or  completed. 


1062 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


One  word  only  have  I to  add  on  the  probable  mechanism  of 
such  cases  of  aneurismal  cyst  as  that  which  occurred  to  myself. 
The  septum  at  its  base  becomes  very  thin ; and  if  it  be  carefully 
dissected  or  boiled,  it  is  found  that,  at  the  base,  its  muscular  fibres, 
gradually  attenuated,  are  stopped  by  cellular  tissue,  and  that  on  the 
base,  as  it  were,  is  fixed  that  part  of  the  heart  containing  the  two 
auricles  and  the  commencement  of  the  pulmonary  artery  and  aorta. 
If,  therefore,  by  any  morbid  action,  the  base  of  the  septum  were 
rendered  fragile  or  brittle,  or  its  cohesion  with  the  auricular  part 
of  the  heart  were  weakened  or  destroyed,  it  is  not  difficult  to  un- 
derstand that  it  might  be  thus  detached,  and  gradually  made  to 
give  way  and  form  an  aneurismal  sac  at  its  base. 

Though  it  is  doubtful  whether  abscess  is  the  cause  of  this  lesion, 

I think  various  facts  show  that  chronic  inflammation  is  the  main 
predisposing  cause  of  its  origin.  In  the  first  place,  the  disease 
takes  place  in  persons  rheumatic  or  gouty,  or  who  have  had  rheu- 
matism ; and  in  whom  often  the  endocardium  is  or  has  been  inflam- 
ed. In  the  second  place,  the  effect  of  inflammation,  it  has  been 
shown,  on  the  muscular  tissue  is  to  destroy  its  elasticity,  to  render 
it  brittle  and  easily  lacerable,  and  sometimes  to  soften  it.  If  there- 
fore inflammation  were  attacking  either  the  endocardium  and  spread- 
ing to  the  muscular  fibres,  or  were  attacking  the  latter  from  the 
first,  it  is  easy  to  see  that  it  might  cause  in  an  organ  so  liable  to 
distension  and  in  action  so  incessant,  laceration.  In  the  third  place, 
we  find  the  lesion  preceded  or  accompanied  by  various  changes  in 
different  textures  of  the  heart,  which  are  generally  regarded  as  ef- 
fects of  chronic  inflammation. 

§ 9.  Atrophy.  Steatosis. — The  muscular  fibres  are  pale,  or 

yellow-coloured,  soft,  flaccid,  and  lacerable.  The  organ  is  small 
and  shrunk,  and  collapses.  Fat-globules  and  cholesterine  are  infil- 
trated into  the  cylinders  of  the  muscular  fibres. 

§ 10.  Malformations. — These  must  be  mentioned  very  shortly. 
The  most  important  are  those  which  cause  the  communication  of 
the  right  and  left  chambers,  or  the  venous  and  arterial  sides  of  the 
heart ; with  various  degrees  of  that  blue  or  violet  colour  of  the 
skin,  called  Kyanosis. 

These  are  the  following.  Is#,  The  foramen  ovale  or  aperture 
of  Botallus,  more  or  less  open,  sometimes  forming  a large  and  direct 
communication  between  the  auricles.  2J,  The  septum  cordis  being 
deficient,  or  open,  or  perforated,  congenital,  or  acquired;  or  the 


MORBID  STATES  OF  THE  HEART. MALFORMATIONS.  1063 


two  last  mentioned  united ; as  in  the  case  by  Landoury.* * * §  Zd,  The 
aorta  arising  in  such  a manner  that  its  orifice  corresponds  to  a con- 
genital aperture  in  the  septum,  most  commonly  at  the  base  of  that 
partition.  Ath,  The  aorta  arising  at  once  from  the  right  and  left 
ventricle,  as  in  the  case  recorded  by  Sandifort,  that  by  Dr  Nevin, 
and  in  the  47th  case  given  by  Gintrac,  the  case  of  M.  Olivry,  in 
the  case  recorded  by  Dr  George  Gregory,  in  one  given  by  Chas- 
sinatjt  and  in  one  given  by  Casper.J  5th,  The  pulmonary  artery 
arising  from  the  left  ventricle,  while  the  aorta  arises  from  the  right, 
as  in  the  case  recorded  by  Baillie,  one  by  Hildehrand,§  and  one  by 
Dr  Walshe.||  Qth,  The  aorta  and  pulmonary  artery  arising  from  the 
left  ventricle,  as  in  the  case  recorded  by  M.  Marechale.  1th,  Only 
one  auricle  and  one  ventricle,  the  latter  giving  rise  to  one  trunk, 
which  afterwards  divides  into  the  aorta  and  pulmonary  artery. 
Zthly,  One  auricle  and  one  ventricle,  giving  rise  to  a separate 
aorta  on  the  right,  and  a pulmonary  artery  on  the  left,  as  in  the 
two  cases  given  by  M.  There. IT 

These  errors  in  formation  may  be  traced  to  one  of  two  causes ; 
arrest  or  interruption  in  the  process  of  development ; and  mis- 
adaptation  of  constituent  parts.  All  of  them,  however,  are  fur- 
ther connected  with  some  form  and  degree  of  that  obstruction  or 
arctation  in  the  orifice  of  the  pulmonary  artery  already  noticed. 
My  limits  and  the  nature  of  this  work  do  not  allow  me  to  enter  into 
detail  on  the  consideration  of  this  subject;  and  all  that  I can  here 


* Observation  de  Communication  Anormale  entre  les  cavites  du  Coeiu',  &c.  Par 
H.  Landoury.  Archives  Generales,  T.  xlviii.  p.  436.  Paris,  1838. 

t Observations  d’Anomalies  Anatomiques  remarkables  de  I’appareil  circulatoire, 
&c.  Par  M.  le  Docteiu-  Raoul  Chassinat.  Archives  Generales  T.  xli.  p.  80.  Paris, 
1836. 

J Wochenschrift  fur  die  Gesammte  Heilkunde.  Herausgegeben  von  den  D.  D. 
Casper,  Romberg  und  v.  Stosch.  Jahrgang,  1841.  No.  13. 

§ Merkivurdige  Missbildung  des  Herzens  und  der  Grossen  Gefiisse.  Von  Dr  Hilde- 
brand. Graefe  und  Walthers’  Journal  der  Chirurgie  und  Augenheilkunde,  Bd.  xxix. 
Heft  3,  Seite  490. 

II  Case  of  Cyanosis  depending  on  Transposition  of  the  Aorta  and  Pulmonary  Artery. 
By  W,  H.  Walshe,  M.  D.  Medico-Chirurgical  Transactions,  Vol.  xxv.  p.  1.  Lond. 
1842. 

II  Memoire  sur  le  Vice  de  Conformation  du  Coeur,  consistant  seulement  en  une 
Oreillette  et  un  Ventricule.  Par  M.  Thore.  Archives  Generales,  T.  lx.  316.  Paris, 

1842. 

Note  sur  une  Anomalie  du  Coeur  chez  un  Enfant  nouveau-ne.  Par  M.  Thore. 
Transposition  of  the  Aorta  which  is  on  the  right  ; the  pulmonary  artery  and  auri- 
cular appendages  on  left ; one  Ventricle.  Archives  Generales,  T.  Ixi.  p.  199.  Paris 

1843. 


1064 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


say  is,  that  the  facts  carefully  examined  render  it  highly  probable, 
that  this  obstruction  and  impediment  in  the  orifice  of  the  pulmo- 
nary artery  is  the  incipient  phenomenon  in  the  series  of  changes,  in 
short,  must  be  regarded  as  the  main  cause  of  those  imperfections,  to 
which  the  name  of  malformations  is  applied.  While  this  impedi- 
ment is  in  any  manner  formed  at  an  early  period  of  foetal  exist- 
ence, the  other  changes  with  hyanosis  follow  as  matter  of  course. 

The  first  two  defects,  foramen  ovale,  and  imperfect  septum, 
are  the  most  usual.  These  are  the  immediate  consequences  of 
arrest  of  development  in  the  formation  of  the  heart. 

In  the  early  period  of  foetal  existence,  it  is  known,  that  the  heart 
consists  of  two  chambers  only,  that  is,  one  auricle  and  one  ventri- 
cle. The  auricle,  in  the  natural  progress  of  formation,  begins 
about  the  end  of  the  second  or  the  beginning  of  the  third  month  to 
be  divided  into  two  portions, — a right  and  left, — by  one  thin  mem- 
brane proceeding  from  its  posterior  surface  forwards,  and  another 
thin  membrane  advancing  backwards  from  its  anterior  surface. 
These  have  crescentic  margins,  which  in  the  natural  course  meet 
and  pass,  overlying  or  imbricating  each  other,  so  as  at  the  period  of 
birth,*  or  soon  after,  generally  to  complete  the  partition.  When 
however,  from  obstruction  or  impediment  in  the  orifice  of  the  pul- 
monary artery,  the  blood  which  enters  the  right  ventricle  cannot 
obtain  by  that  vessel  and  the  ductus  arteriosus,  a ready  outlet,  its 
copious  passage  from  the  right  to  the  left  division  of  the  auricle 
continues  uninterrupted  and  undiminished,  and  the  membranous 
folds  are  not  only  prevented  from  meeting  and  overlapping  each 
other,  but  their  increase  is  suddenly  stopped,  and  i\\Q  foramen  ovale 
remains  unclosed. 

The  septum  of  the  ventricles  is  a growth  partly  from  the  poste- 
rior wall  of  the  common  single  ventricle,  partly  from  the  anterior 
wall,  beginning  at  the  apex  and  proceeding  in  growth  towards  the 
base.  In  the  early  period  of  foetal  existence,  the  blood  which  enters 
the  right  ventricle,  and  which  is  supposed  to  be  chiefly  that  which 
comes  from  the  head,  neck,  and  superior  extremities,  enters  also 
the  left,  and  there  partly  proceeds  to  the  aorta  without,  it  is  be- 
lieved, entering  the  pulmonary  artery.  There  is  at  least  nothing 
to  prevent  this,  as  the  right  ventricle  communicates  directly  with 
the  left  at  the  base  till  the  seventh  week,  when  the  opening  is 
still  large.  As  intra-uterine  life  advances,  however,  provision  is 
made  for  stopping  this  by  the  gradual  growth  of  the  septum  towards 

the  base  ; and  at  the  end  of  the  second  month  the  septum  is  usually 

4 


MORBID  STATES  OF  THE  HEART — HETEROLOGOUS  GROWTHS.  1065 

completed,  and  the  orifice  is  closed.  This  growth,  however,  may  be 
interrupted  at  any  stage  of  its  progress,  early  or  late ; and  the  in- 
terruption is  most  likely  to  take  place,  when  the  orifice  of  the  pul- 
monary artery  is  small  and  more  or  less  obstructed.  If  the  inter- 
ruption take  place  early,  the  septum  is  very  imperfect,  perhaps  per- 
forated in  the  middle.  If  it  take  place  late,  it  is  still  imperfect, 
though  less  so,  and  is  deficient  only  at  the  base  of  the  heart,  so  as 
to  allow  blood  easily  to  enter  the  aorta.  Hence  it  results  that  the 
septum  is  imperfect  or  perforated,  and  that  often  with  that  is  ne- 
cessarily conjoined  either  the  aorta  communicating  with  the  right 
ventricle,  that  is,  its  orifice  corresponding  with  an  aperture  in  the 
septum,  or  arising  from  that  chamber  and  the  left  at  once. 

The  rare  example  of  the  heart  consisting  of  only  one  auricle  and 
one  ventricle  is  merely  the  extreme  degree  of  this  form  of  arrest 
of  development. 

The  case  of  the  pulmonary  artery  arising  from  the  left  ventricle, 
while  the  aorta  issues  from  the  right,  takes  place  in  a different 
manner.  A degree  of  mal-apposition  in  the  vessels  and  the  ven- 
tricle must  have  taken  place  at  an  early  period  of  foetal  existence. 
This  we  know  takes  place  with  other  organs,  with  bones  for  instance, 
and  with  certain  portions  of  the  abdominal  and  thoracic  viscera. 

All  these  lesions  now  mentioned  are  in  different  degrees  incom- 
patible with  the  continuance  of  life.  Their  incompatibility  is  very 
nearly  in  the  oi’der  in  which  they  are  arranged.  But  to  this  must 
be  added,  that  their  incompatibility  and  fatality  are  regulated,  to  a 
certain  extent,  by  the  degree  in  which  the  orifice  of  the  pulmonary- 
artery  is  contracted  and  obstructed.  If  the  contraction  be  not 
very  great,  life  may  be  continued  for  years ; and  the  individual, 
though  feeble,  and  evidently  imperfectly  nourished,  may  attain  the 
adult  age  or  beyond  that.  If  the  contraction  be  greater,  and  so 
considerable  that  the  blood  does  not  readily  enter  the  orifice  of  the 
artery,  though  he  attain  the  age  of  puberty,  life  is  rarely  pro- 
longed beyond  that  period.  Kyanosis  is  considerable  and  almost 
constant.  If  the  aperture  be  still  smaller,  the  individual  dies  in 
infancy,  or  may  be  cut  off  a few  days  after  birth.  And  w-hen  the 
artery  is  entirely  obstructed,  death  takes  place  shortly  after  birth. 

§11.  Heterologous  Growths. — The  heart  is  observed  to  be  in- 
volved in  enkephaloma  when  that  structure  appears  in  the  lungs  and 
in  the  liver ; and  it  is  also  affected  by  the  melanotic  deposit.  In 
the  first  case  the  enkephaloid  matter  forms  a species  of  investing 
mass  encroaching  on  the  whole  substance  of  the  heart.  In  the 


GENERAL  AND  PATHOLOGICAL  ANATOMY. 


ldl)6 

latter  case,  the  melanotic  deposit  may  either  appear  in  this  manner, 
or  it  may  be  infiltrated  into  the  substance  of  the  organ. 

§ 1 2.  Ektopia.  Displacement. — The  heart  is  pushed  to  the 
right  side  in  cases  of  empyema  of  the  left  pleura,  with  copious  eflFu- 
sion.  This,  however,  is  the  mere  effect  of  the  effusion  ; and  dis- 
appears when  that  is  absorbed.  This  is  not  ektopia. 

This  terra  is  applied  to  those  displacements  of  the  heart,  in  which, 
from  some  deficiency  in  the  formation  of  the  enclosing  parts,  as  the 
sternum,  the  ribs,  tbe  diaphragm,  the  heart  is  found  in  a situation 
different  from  its  natural.  The  common  point  or  character  is,  that 
the  heart  is  out  of  the  cardiac  region  ; and  it  may  be  either  in  that 
of  the  head,  that  of  the  chest,  or  that  of  the  abdomen.  The  first 
is  rare.  The  second  and  third,  which  are  more  common,  have 
been  distinguished  by  Fleischmann  and  Weese  under  the  names 
of  Ektopia  Pectoralis  and  Ektopia  Ventralis. 

Under  the  head  of  Ectopia  Pectoralis  are  comprehended  all  those 
instances  of  displacement,  in  which  the  heart  protrudes  on  the  sur- 
face of  the  chest,  either  with  deficiency  of  the  sternum  and  ribs, 
or  these  remaining  entire,  at  either  extremity  of  the  sternum. 

Under  the  head  of  Ektopia  Ventralis  are  comprehended  those 
instances  in  which,  from  deficiency  of  the  diaphragm,  the  heart  is 
protruded  among  the  abdominal  viscera. 

In  the  first  case  it  is  rare  to  find  the  heart  protruded  without 
deficiency  of  the  sternum  and  ribs.  It  has  been  observed,  however, 
by  Weese  in  the  sheep.  More  commonly  the  sternum  is  wanting, 
or  it  is  divided  by  a fissure.  With  this  other  malformations  are 
usually  associated ; for  instance  the  foramen  ovale  open,  the  septum 
perforated,  and  the  aorta  connected  with  both  ventricles.  The 
pericardium  is  sometimes  wanting ; and  in  some  instances  the  me- 
diastinum is  deficient. 

Ektopia  Ventralis  may  be  attended  either  with  integrity  or  more 
or  less  deficiency  of  the  sternum  and  ribs.  The  prolapsed  heart 
is  sometimes  surrounded  by  a membrane  like  that  of  a hernial  sac. 

To  these  forms  of  Ektopia  Breschet  has  added  that  in  the  region 
of  the  head,  Ektopia  Cephalica. 

For  details  I refer  to  the  Commentary  of  Weese,*  and  the  Me- 
moir of  Breschetf 

* De  Cordis  Ectopia  Commentatio  Anatomico-Pathalogica.  Auctore  Carolo  Weese, 
M.  et  Cli.  D.  Accedunt  Tabulae  Aenese  vi.  Berolini,  1819.  4to. 

-]-  Memoire  sur  TEctopie  de  I’Appareil  de  la  Circulation,  et  particulierement  sur 
celle  dll  Coeur.  Par  G.  Breschet,  D.  M.  &c.  Repertoire  Generate,  T,  ii.  p.  1.  Paris, 
1826. 

6 


INDEX 


Abscess  of  the  brain  . Page  283 

connection  with  abscess  and 

gangrene  of  the  lungs  . 285 

connected  with  disease  of  the 

internal  ear  . . 286 

in  the  heart,  instances  of  402,  1043 

in  nver,  connection  between 

and  injuries  of  liver  and  phlebitis, 
868,  876 

of  lungs,  on  . . 997 

in  testis  . . . 968 

Absorption,  interstitial,  of  bones  488 
Acephalocysts  in  bone  . . 489 

in  brain  . . 350 

in  cellular  tissue  or 

adipose  . . . 75 

in  heart  , , 410 

in  liver  . 905 

in  lungs  . 1 036 

in  mucous  membranes  678 

in  serous  membranes  741 

Acini,  their  nature  . . 768 

Addison,  Mr  William,  his  researches 
on  the  air-cells  of  the  limgs  . 977 

Adenoma  of  brain  . . 333 

Adenosis,  inflammation  of  lymphatic 
glands  . . . 217, 218 

Adipose  membrane,  its  anatomical 
characters  and  distribution  . 49 

its  diseased  states  55 

the  seat  of  difiuse 


inflammation  . . .58 

Adhesion  in  mucous  surfaces  . 670 

Akinopyesis,  suppuration  of  acini  of 
Mver  ....  904 
Anatomy,  general,  its  history  . 1 

Aneurism,  its  nature,  causes,  and  va- 
rieties . . .98,  102 

in  arteries  of  brain  . 7 34 

varicose  . . 104 

Air-cells,  recent  researches  on  their 
existence  and  characters  . 97 6 

Akne,  its  seat  . . 526,  529 

Anenkephalia,  deficient  formation  of 
brain,  its  nature  and  causes  . 355 

Aneurism,  partial,  of  heart,  its  nature 
and  characters,  . . 1054 

Angiektasis,  capillary  aneurism  of 
bones  . . . 489 


of 


skin  , . . 540 

AngioUucitis,  its  characters  and 
causes  . . .211 

Aorta,  contraction  and  obliteration 
of  ...  85,110 

Aortic  valves,  morbid  states  of  . 91 

Aphtha,  its  seat  and  characters  . 570 

Apoplexy,  febrile,  its  nature  and  pa- 
thology . . . 304 


Apoplexy,  traumatic,  or  that  from 
violence  . . Page  305 

its  anatomical  characters  316 

neonatorum,  in  infants  307 

nervous,  its  true  nature  308 

state  of  brain  and  its  ves- 
sels in  . . .291 

Arachnoid  membrane,  its  characters 
and  distribution  . . 695 

Arctation  of  bronchial  tubes  . 600 

Artery,  its  anatomical  characters  and 
distribution  ...  76 

Arteries  distinguished  into  orders  83 

morbid  states  of  . 87 

Arthropyema  after  phlebitis  . 7 34 

Atheroma,  characters  of  . 201 

Atheromatous  deposition  in  arteries  95 
Atrophy  of  the  brain,  its  characters 
and  causes  . . 330 

Atrophy  of  muscles  and  muscular 
organs  . . . 407 

Atrophy  of  pancreas  . . 847 

of  liver  . . . 886 

of  kidney,  two  forms  of  . 961 

of  breasts  . . 964 

of  testis  . .970 

of  heart  . . 1062 

of  the  valves  of  the  heart  1046 

of  limbs  dependent  on  atro- 
phy of  brain  . . 357 

Bichat,  his  services  to  general  anatomy  8 
Bidder,  his  researches  on  the  Malpig- 
hian bodies  . . 996 

Bilious  pneumonia  . . 990 

Blebs  or  bulla,  their  seat  . 508 

Blennorrhoea  . . . 654 

Blood,  its  constitution  . 1 8 

Blood  deposits  in  pulmonary  arteries  1000 
BoU,  its  seat  and  natme  . 527 

Bone,  on  its  minute  structure  427,  431 

its  development  . 436 

on  morbid  states  in  . 444 

Bonn,  Andrew,  his  merits  in  general 
anatomy  ...  6 

Bony  induration  of  muscles  . 409 

Bourgery,  his  researches  on  the  ends 
of  the  bronchial  tubes  . 97 6 

Bo^vman,  his  researches  on  the  Mal- 
pighian bodies  . . 791 

Brain,  structure  of,  and  its  parts  223 

microscopical  anatomy  of  268 

morbid  states  of  . . 277 

aneurisms  in  arteries  of  . 734 

Bronchi,  membranes  spit  up  from  578 
Bronchial  tubes,  on  their  terminations  97 6 
Bronchitis,  acute  and  chronic,  its 
seat,  nature,  and  effects  . 578 

from  foreign  bodies  in  wind- 
pipe and  bronchi  . . 584 


1068 


INDEX, 


Ctecum,  inflammation  of  Page  632 

Calcareous  and  osseous  deposits  in 
brain  . . .347 

concretions  in  lungs,  on 

their  origin  and  indication  1033,  1035 


Capillary  vessels,  system  of,  characters  131 

—  morbid  processes 

taking  place  in  . .136 

Cartilage,  its  structure  and  forms  490 

its  morbid  states  . 492 

adventitious  deposits  of,  in 

serous  membranes  . . 740 

Cartilaginous  union  of  ribs  and  other 
bones  . . . 478 

Cauliflower  excrescence  of  the  uterus  680 
Cerebellum,  morbid  states  of  . 300 

Cheloid  tumour  . . 541 

Chest,  malformation  in  bones  of  478,  481 
Chondroma,  character  of  in  brain  344 

of  serous  membranes  740 

Chondrosis  of  ureters  . 943 

Choroid  plexus,  inflammation  in  724 

Cirsoid  aneiu’ism,  its  characters  100 

Coal  miners’  lung,  on  its  nature  1041 
Colloid  cancer  in  mucous  membranes  676 
Conarion  or  pineal  gland,  morbid 
states  of  . . . 349 

Concretions,  lacrymal  . 827 

salivary  . . 829 

in  pancreas  . 848 

in  hepatic  ducts  . 903 

in  gall  bladder  and  ducts  919 

Congestion,  on  its  characters  . 139 

Consolidation  of  lungs,  on  its  nature 
and  causes  . . 983 

Contraction,  morbid,  of  hand  and  fin- 
gers , . . 421 

Corpuscula  of  bone  described  432 

Croup,  its  nature  and  scat  . 577 

Cystidia,  chronic  inflammation  of 
bladder  . . . 657 

Cystirrhoea,  suppurative  catarrh  of 
bladder  . . . 655 

Cystosarkoma  of  mamma  . 963 

.in  testis  . 971 

Cysts  in  cellular  tissue  . 48 

in  kidney  . . 961 

in  liver  . . 909 

in  mamma  . . 963 

in  testis  . . 971 

Delirium  talcing  place  in  the  phthisical  722 
Demodex  Folhculorum,  the  follicular 
worm,  its  characters  . 530 

Desmodia,  inflammation  of  ligament 
and  fascia  . . . 417 

Desmosis  of  testis  . . 970 

Diastasis  or  separation  of  epiphyses  447 
Diffuse  inflammation,  its  pathological 
characters  ...  37 

Dilatation  of  bronchi  . . 605 

—  the  effect  of 

aneurismal  tumours  . 606 


Dilatation  of  the  heart  Page  1050 

Disjunctive  inflammation,  its  seat  and 
characters  . . .58,  67 

Displacements  of  mucous  membranes  680 
Diverticula  . . . 682 

Dropsies,  causes  of  . . 191,709 

Duodenum,  morbid  states  affecting  620 
Dura  mater,  thickening  of  . 743 

Dysentery,  its  seat  and  characters  639,  640 
Ear,  disease  of,  giving  rise  to  abscess 

of  brain  . . . 286 

Echinococcus  in  the  liver  . 908 

Ekthyma,  characters  and  seat  . 525 

Ektopia  of  heart  . . 1066 

Elephantiasis,  its  nature  . 1 94 

Emphysema,  superficial,  yimermaiosts  46 

of  lungs  594 

Empyema,  its  causes  and  nature  7 1 3 
Enkephalin,  its  nature  . . 277 

Enkephalaemia  or  apoplexy,  state  of 
brain  and  vessels  in  . . 291 

Enkephalelleipsis,  deficiency  of  brain 
or  its  parts,  its  causes  . 355 

Enkephaloma  in  bones  . . 488 

in  brain  . . 352 

in  joints  . . 756 

in  kidneys  . 963 

in  liver  . . 911 

in  lungs  . . 1036 

in  mamma  . 967 

in  pancreas  . 851 

in  serous  membranes  742 

in  testis  . . 971 

Entqzoa  in  brain  . . 904 

in  liver  . . .917 

in  lungs  . . 1036 

Enteria  (enteritis  mucosa)  . 620 

Epiphora,  its  seat  . . 568 

Erectile  system,  its  anatomical  cha- 
racters . . . 169 

its  morbid  states  1 7 6 

Exanthemata,  their  seat  . 506 

Exfoliation  of  bones,  different  sorts  of  450 
Exhalant  vessels,  their  characters  187 


morbid  states  in 


them  . . .190 

Exostosis,  different  sorts  of  451,  474 

medullary  exostosis  474 

Fascia,  palmar,  chronic  inflammation 
and  contraction  of  . . 42) 

Fat-globules  in  the  renal  tubules  in 
granular  disease  . . 953 

in  arteries  . 1046 

in  liver  . . 901 

in  heart  . . 1 062 

Fever,  on  the  state  of  the  vessels  in  156 

on  the  state  of  the  blood  in  1 63 

state  of  the  brain  in  . 316 

Fibrous,  white,  system,  its  structure 
and  distribution  . . 414 


— diseases  tak- 


ing place  in  . . . 417 


INDEX, 


1069 


Fibrous  and  fibro-cartilagiiious  tu- 
mours . . Page  745 

Fibro-cartilage,  its  structure  and  forms  494 

its  morbid  states  495  : 

Fibro-serous  membranes,  m orbid  states  ! 

affecting  . . . 743 

Fibrous  tissue,  on  the  white  . 414  | 

on  the  yellow  . 426  : 

Filamentous  tissue,  its  anatomical  [ 

characters  and  distribution  . 30  ; 

its  morbid  states  35  I 


Fistulae,  congenital,  in  neck,  their  ori- 


gin  from  the  branchial  slits 

682 

FistultB  of  mucous  cadties 

683 

Fleshy  tubercle  of  the  womb 

679 

Fluids  in  their  soimd  state 

18 

in  morbid  state 

24 

Follicles  cutaneous, their  diseased  states  529 

parasitical  animal  of 

530 

of  mucous  membranes 

. 555 

diseases  affecting 

621,  643 

Follicular  enteritis  . 625,  643  j 

fever  . . 626 

Fragility  of  bones  . . 488  i 

Fungus  hjematodes  in  different  or-  | 
gans.  See  enkephaloma 
Gall-stones,  their  effects  . 919,  920 

Ganglions,  structure  of  . 365,  371  j 

functions  of  . 373  ] 

Gangrene  as  an  effect  of  inflammation  156 

of  the  liver  . 876 

of  the  kidney  . 941 

of  the  lungs  . 992 

Gerlach,  his  researches  on  the  Malpi- 
ghian bodies  . . 794 

Glands,  lymphatic,  their  anatomy,  215 

morbid  states  of  . 217 

of  mucous  membranes  . 555 

diseases  affecting  , 621 

secreting,  on  their  structure  in 

general  , . . 757 

diseased  states  affecting  811,  813 

Granular  disease  of  liver  . 887 

of  kidney  . 946 

Grinders  asthma  or  bronchitis,  its  na- 
tvrre  and  forms  . . 597 

Gumma,  periosteal  swelling  so  called  448 
Hairs,  structure  of  ; . 547 

Haller,  his  services  to  general  anatomy  4 
Hsematoma,  the  blood-cyst,  characters 
of  . . , . 198 

in  brain  . 351 

in  bone  . . 483 

Heart,  abscess  of,  its  characters  402,  1043 
Helicine  arteries,  their  characters  173 
Hemorrhages,  physiological  causes  of  193 
Hemorrhage  from  the  skin  . 538 

from  the  liver  . 881 

from  the  mucous  mem- 
branes . . . 663 

from  the  serous  mem- 
branes . . . 729 


Hepatitis,  its  nature  and  varieties  Page  853 


Histology  or  doctrine  of  the  elemen- 
tary tissues  . . 1 , 10 

Hydatids  in  adipose  tissue  . 75 

in  bone  . . 489 

in  brain  . . 350 

in  heart  . . 410 

in  liver  . . 905 

in  lungs  . . 1036 

in  mamma  . 963 

in  mucous  membranes  . 678 

in  serous  membranes  . 1036 

Hygroma  or  hydatoma,  the  serous 
cyst  in  . . . 198 

or  hydatoma  in  liver  . 908 

^ in  kidney  . . 961 

in  mamma  . 963 

Hymenarthritis,  characters  of  . 748 

Hypertrophy  as  an  effect  of  inflam- 
mation . . . 168 

of  the  brain,  its  nature  327 

of  the  spleen  . 183 

of  the  liver 

of  muscles  and  muscular 

organs  . . . 406 

of  the  heart  . 1005 

of  the  bronchi  . 644 

of  the  pancreas  : 819 

of  the  parotid  gland  883 

of  liver  . . 862 

of  the  kidnej'  . 964 

— — of  mamma  . 964 

of  prostate  gland  . 972 

Ileo-coecal  inflammation  & abscess  42,  632 
Ileum  and  ileal  fo Hides,  tubercular  - 
disease  in  . . 650 

Imperforations  . . 682 

Indmation  of  cellular  tissue  . 43 

as  an  effect  of  inflamma- 
tion . . . 155 

of  the  brain  320,  325 

spleen  . 185 

lungs  . 983,  1009 

of  intestines  . 645 

glands  812,  818,  820 

Inflammation,  on  the  state  of  the  ves- 
sels in  . . .137 

Inflammatory  dropsy  . 711 

Insanit}-,  state  of  cerebral  membranes 
in  _ . . . 724 

Intestines,  state  of,  in  fever  . 648 

pulmonary  con- 
sumption . . 1030 

Itch  insect,  its  history  . 543 

Ivory,  degeneration  in  bones  489 

Kaltenbrimner,  accoimt  of  his  views 
and  researches  . . 140 

Keloid  tumour  . . 541 

Keroma  of  brain  . . 341 

characters  of,  in  muscles  410 

Kidneys,  minute  structure  of  781 

morbid  states  affecting  929 


1070 


INDEX, 


Kiernan,  Mr,  his  researches  on  the  struc- 


ture of  the  liver  . Page  780 

Kinetic  textui'es,  anatomy  of  395 

Kirrhosis  of  liver,  its  characters  and 
nature  . . . 887 

of  lung,  its  characters  1034 

Kii-sus,  its  nature  . . 212 

Kolliker,  his  researches  on  the  Mal- 
pighian bodies  . . 802 

Kolloides  of  brain,  its  characters  340 
Kolloid  cancer  in  a stomach  676 

in  mamma  . 966 

in  testis  . 971 

Kyanosis,  its  causes  . 1062,  1064 

Laceration  of  the  brain  . 299 

muscles  . 409 

the  heart  . 409 

Laryngitis,  its  seat  . . 571 

chronic  . . 572 

Liver,  its  structure  . . 774 

morbid  states  affecting  853 

Lobular  pneumonia,  its  seat  and  cha- 
racters . . . 989 

Lungs,  their  minute  structure  973 

morbid  states  . 981 

Lupia,  encysted  tumour,  characters 
of  ...  203 

Lymph,  on  its  production  and  na- 
ture . . 143,  144 

Lymphatic  system,  anatomical  struc- 
ture and  distribution  . 204 

morbid  states  of 

and  affecting  . . 210 

glands,  their  anatomy  215 

morbid  states  217 

Malakenkephalon,  diminished  consist- 
ence of  the  brain,  its  causes  31 7 

Malakosis  of  pancreas  . 845 

ofUver  . . 878 

Malformations  on  the  mucous  mem- 
branes . . . 681 

Malformation  of  the  heart  1062 

Malignant  pustule,  its  nature  525 

Malpighi,  his  merits  as  an  anatomist  3 
Malpighian  bodies,  on  their  structure  789 
Mamma,  its  minute  structure  810 

morbid  states  of,  and  affecting  963 

Marasmus,  see  peritonitis  . 720 

Margaroides  or  cholesterine  tumour 
of  brain,  characters  of  . 343 

Marrow,  its  anatomical  disposition  436 
Medullary  membrane,  its  nature  and 
distribution  . . 436 

Medullary  sarkoma  in  various  organs, 
see  Enkephaloma  352,  971,  967 

Melanosis,  occasionally  encysted,  in 
brain  . . . 204 

in  heart  . . 353 

in  liver  . . 916 

in  lungs  . . 1040,  104 

in  muscles  . 410 

in  pancreas  . 853 


Melanosis,  spurious,  or  from  inhalation  of 


black  matter  . Page  1041 

Melikeris,  characters  of  . 200 

in  skin  . . 540 

Melituria,  its  characters  . 29 

Membranes,  their  anatomy  . 497 

mucous,  their  structure 

and  varieties  . . 548 

diseased  states  in  . 566 

Meningeal  irritation  in  fever  . 722 

hemorrhages,  nature  and 

characters  of  . . 730 

Meningitis,  seat  of  . . 721 

chronic,  its  state  in  the  insane  724 

Milzbrand,  its  nature  . . 525 

Mollities  ossium,  on  . . 485 

MoUuskum,  its  seat  and  forms  532 

Morbid  development  of  exhalants  197 

Mucous  membranes,  structure  and  dis- 
tribution of  . . 548 

diseases  in,  and 

affecting  , . . 566 

Muscle,  anatomy  and  microscopical 
structure  . . . 395,  399 

morbid  states  of,  and  affecting  401 

Nails,  anatomy  of  . . 547 

Nekrosis,  its  nature  and  causes  453 

different  theories  on  459 

Nephritis  . . . 929 

Nephropyema  . . . 936 

Nerves,  their  anatomical  structure 
and  distribution  . . 359 

microscopical  structure  of  37 1 

morbid  states  of,  and  in  379 

Neuralgia,  on  its  seat  and  nature  380 
Neurilema,  its  structure  and  arrange- 
ment . . . 360 

morbid  states  of  . 379,  381 

Neurilemmia,  its  nature  and  effects  381 
Newitis,  its  characters,  causes,  and 
effects  . . . 379 

Neuroma  or  nerve-swelling,  its  cha- 
racters . . . 387 

Neuromation  or  small  nerve-swelling  391 
Node,  periosteal  swelling,  its  nature  448 
Obliteration  of  arteries  85,  109, 110 

of  bronchial  tubes  . 600 

of  veins  . . 127 

Obstruction  of  the  tuhuU  testis  . 968 

Occlusion,  or  obstruction  of  arteries  106 

— of  pulmonary  artery  . 1049 

Qilsophagus,  its  diseases  , 607 

Ophthalmia,  its  seat  . 567 

Orchitis,  its  seat  and  effects  . 968 

Organization,  distinctive  characters  of  225 
Ossification  of  arteries  . . 92 

of  serous  membranes  740 

of  veins  . . 130 

Osteitis,  its  phenomena  and  effects  444 
Osteo-sarkoma,  its  seat  and  nature  451 
Osteo-steatomatous  state  of  cerebral 
arteries,  causing  cataphora  . 732 


INDEX. 


1071 


Otitis,  its  seat  . . Page  569 

Paedarthrokake,  its  characters  and 
causes  . • . 475 

Pancreas  of  the  sturgeon,  its  structru-e  764 

of  mammalia,  its  structure  776 

diseased  states  affecting  831 

Parasitical  animals  in  skin  . 543 

Parotid  gland,  diseased  states  affecting  816 

tumours  involving  825 

Pellagra,  its  nature  . . 537 

Pericardial  hemorrhage  . . 735 

Pericardium,  its  characters  . 689 

Periosteum,  its  influence  in  ossifica- 
tion ....  423 

Periostitis,  its  seat  and  effects  418,  448 
Peritoneal  hemorrhage  . . 736 

Peritonseum,  its  extent  and  distribu- 
tion • . . 684 

diseased  states  affecting  698 

Peritonitis,  puerperal  . 716 

chronic  . . 720 

Perityphlitis,  its  seat  and  nature  632 
Peyer’s  glands,  their  seat  and  struc- 
ture . . . 555,  556 

diseases  affecting  621,  625 

Phthisis  laryngea,  its  seat  . 573 

pulmonaUs,  state  of  lungs  in  1009 

state  of  other  or- 
gans in  . . . 1030 

Phlebitis,  its  seat,  causes,  and  effects 

124,  128 

followed  by  pm’ulent  de- 
posits within  joints  . . 754 

hepatic,  circumstances  un- 
der which  it  occurs  . . 879 

pulmonary,  its  nature  999 

Phleboliths  or  vein  stones  130,  1036 
Pia  mater,  characters  and  distribu- 
tion of  . . . 692 

Pimples,  their  characters  . 509 

Pleurisy^  chronic,  its  seat  . 713 

Plexus,  nervous,  structure  and  ^ar- 
rangement of  . . . 368 

Pneumonia,  on  its  characters  and  seat  981 
Pneumothorax,  its  nature  and  seat  7 37 
Poisons,  effects  of  corrosive,  on  sto- 
mach . . . 616 

Polypus,  its  forms  . . 672 

Pori  of  Havers  in  bone  . 429,  430 

Puerperal  peritonitis  . . 716 

Pulmonary  artery,  blood  deposits  in  1000 

obstruction  of  1049 

apoplexy  or  hemorrhage, 

pathology  of  . 1001,  1004 

Purulent  collections  within  joints  af- 
ter phlebitis  . . . 754 

Pustules,  their  seat  and  forms  . 518 

Rainey,  Mr  George,  his  researches  on 
the  air-cells  of  the  lungs  . 97 9 

Ranula,  its  nature  . 820,  830 

Reichert,  his  views  as  to  the  Malpig- 
hian bodies  . . .794 


Reparation  of  bone,  on  the  agents  of 

Page  460 

Reticular  cancer  in  mucous  surfaces  676 

in  mamma  . 966 

Reunion  of  nerves  . . 383 

Reynaud,  his  examination  of  the  ter- 
minal ends  of  the  bronchial  tubes  976 
Rheumatism  seated  mostly  in  fascia  420 

affecting  the  synovial 

membranes  . . .751 

Ribs,  cartilaginous  union  of  . 478 

Rickets  on  nature  and  characters  482 

Rupture  of  muscular  organs  . 408 

of  the  heart  . . 409 

Ruysch,  his  services  to  minute  ana- 
tomy ...  4 

Salivary  glands,  their  structure  775 

morbid  states  affecting  813 

Sarkoma  in  cellular  tissue  . 46 

— in  adipose  membrane  73 

Schroeder,  his  researches  on  the  seat 
of  pulmonary  tubercles  . 1017 

Scaly  diseases,  their  seat  and  causes  510 
Serous  membranes,  their  structure, 
distribution  . . 683 

and  varieties  689 

diseases  affecting  697 

Sinew,  structure  of  . . 412 

diseases  occurring  in  . 413 

Sivvens,  their  nature  and  origin  537 

Skin,  its  structure  . . 497 

morbid  states  in  and  affecting  504 

Skirrhus  in  mucous  membranes  675 

of  pancreas,  doubtful  , 839 

on  its  nature  . . 848 

of  mamma,  its  nature  and 

varieties  . . . 965 

in  testis  . . 971 

in  skin,  mostly  in  tubercular 

forms  . . . S44 

of  skin  . . 542 

Skleroma  of  brain  . . 332 

of  intestines  . . 645 

of  pancreas  . . 337 

of  hver,  incipient  kh-rhosis  865 

of  ureters  . . 943 

Sklerenkephalia,  induration  of  the 
brain,  its  nature  and  character  320,  325 
Small-pox,  morbid  anatomy  of  . 519 

effects  on  mucous  mem- 
branes . . . 649 

Sloughing  in  the  mucous  membranes, 
its  nature  . . . 662 

Softening  as  an  effect  of  inflammation  154 

of  the  brain,  on  its  natirre 

and  characters  . . 278 

of  the  spleen,  on  its  nature  160 

of  the  pancreas  . 845 

of  muscles,  an  effect  of  in- 
flammation . . 404,  406 

Spina  ventosa,  its  nature  and  charac- 
ters , . . 464 


J072 


INDEX. 


Spinal  nianow,  lieniorrluige  from  Page  312 

■ within  its 

sheath  . . . .735 

disease,  disease  of  l<idne3'S  imi- 
tating . . . 944 

Spleen,  its  minute  structure  . 174 

its  morbid  states  . 179 

Steatoma,  characters  of  . 201 

Steatomatous  or  fatty  depositions  in 
arteries  ...  96 

state  of  arteries  de- 
pends on  fat  or  cholesterine  . 1046 

state  of  cerebral  arte- 
ries causing  cataphora  . 732 

Steatosis  of  muscles,  its  nature  . 407 

of  the  heart  . . 407 

of  liver  . . 900 

of  kidneys,  granular  disease  of  946 

Stereomorphic  textures,  theiranatomy  395 
Stomach,  its  diseased  states  . 607 

chronic  ulcer  of  . 609 

softening  of  . .616 

Stricture,  inflammatory,  its  nature  668 
Struma  in  liver,  characters  of  . 910 

Suppuration  as  an  effect  of  inflam- 
mation . . .149 

in  the  heart,  instances  of 

402,  1043 

of  pancreas  . 833 

of  liver  . 859,  862 

— metastatic,  and  after 

phlebitis  . . . 867 

Suppurative  inflammation  of  kidney  942 
Synovial  membranes,  structure  of  . 746 

morbid  states  in  748 

in  rheumatism  . 751 

Teeth,  on  their  structure  and  develop- 
ment , . . 441 

morbid  states  in  . . 489 

Tendon.  See  Sinew  . . 412 

morbid  states  affecting  . 413 

Testis,  its  structure  . . 805 

its  diseased  states  . 967 

Tetanus,  or  lock-jaw,  on  its  pathology  385 
Thecal  inflammation  . .750 

Thrush,  its  seat  and  characters  . 57  0 

Trachea,  ulceration  affecting  . 575 

state  of,  in  the  phthisical  1029 

Trichina  spiralis,  a microscopical 
worm  in  muscle  . . 411 

Tubercles  in  liver,  characters  of  . 911 

imlmonary,  not  from  dis- 
eased glands  . . 1015 

different  kinds  of  1020,  1023 

Tubercular  disease  in  the  serous 
membranes  . . .737 

disease  in  ileum  and  fol- 
licles . . . 650 


Tuberculation  of  glands,  on  its  dha- 
racters  . . Page  222 

of  lungs,  seat  and 

mode  of  formation  . 1008,  1016 

Tumours  of  and  in  the  brain  . 332 

Turgor  vitahs,  its  physiological  causes  175 
Tympania  (inflammation  of  tympanal 
cavity)  . . . 57  0 

Typhlitis,  its  seat  and  forms  . 632 

Typhoid  jmeumonia,  its  characters  991 
Tj'phus,  intestinal,  its  true  nature 

626,  628,  629 

Tj'roma  of  brain  . . 337 

Tyromatosis  of  lungs  . 1008,  1015 

see  tubercles  and  tuber- 
culation . . . 1008 

Tj'romatous  deposit  in  lymphatic 
glands  . . . 222 

in  secreting 

glands  853,  910,  943,  963,  969,  972 

deposition  in  mucous 

membrane  . . 674 

deposit  in  serous  mem- 
branes, especially  ireritonaeum  737 

or  tubercular  disease  in 

testis  . . . 969 

Ulcer,  chronic,  of  stomach  . 609 

Ulceration  of  brain  . . 291 

of  cartilages  . 492 

as  an  effect  of  inflamma- 
tion . . .153 

of  intestines  . 630 

Ulcers  of  larynx  and  windpipe  575 

Ulceration  of  nerves  . . 383 

Urea,  its  chai'acters  . . 23 

in  blood  ...  27 

Urethra,  purulent  inflammation  in  654 

Vagina,  affections  of  . . 661 

Varix,  its  nature  . . 129 

aneurismal  . . 104 

Veins,  structure  and  distribution  of  112 

diseased  states  of  . 124 

Velvet-like  degeneration  of  synovial 
membrane  . . .750 

Vesicles,  their  seat  . . 512 

Villi,  on  their  nature  . . 653 

Villous  membranes  . 548,  553 

5 diseases  in  . 566 

Vomica,  definitions  of  . . 997 

Water  in  brain,  see  meningitis  . 721 

Wolffian  bodies,  their  nature  . 783 

Womb,  its  profluvial  diseases  . 659 

Worms  in  muscles  . . 411 

in  lungs  . . 1 037 

in  follicles  of  skin  . 530 

Yaws,  their  characters  and  nature  535 

Yellow  fibrous  tissue,  its  structure 
and  properties  . . 426 


EDINBURGH  : PRINTED  BY  STARK  AND  COJIPANV, 
OLD  ASSEMBLY  CLOSE. 


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